Archived: Bradbury House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Improvements had been made to the management of the service. A range of audits were now undertaken regularly, and these were checked by senior managers. People, their relatives and staff now had a range of ways in which they could feed back their views. Staff meetings were now frequent. Improvements had been made to some areas of training such as supporting people with learning disability and autism. However, the service was not able to demonstrate some aspects of staff training were up to date. For example, some care staff hadn’t completed diabetes training. The new manager was aware of this and was planning to address this. Where action plans were needed these were now in place. There was a management structure in place and staff understood their roles. Accidents and incidents were recorded and analysed to spot trends and patterns. Staff and people had the opportunity to feed back to the management team through regular meetings if they had any concerns or suggestions. The service worked in partnership effectively with health and social care professionals to improve outcomes for people.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff feedback throughout the survey indicated there was a good understanding of the providers vision and values, which were based on empowering and supporting people through their life journey. The new manager was positive about the service and staff team. They also told us they were keen to improve staff training and to empower staff to drive forward innovation such as creative ideas for activities for people living with dementia. The new manager was aware of the importance of having open communication with staff and promoting a positive culture. Staff were positive about their role and told us they felt supported. One staff said, “I get on very well with the managers. They are supportive and approachable.” Another said, “The managers are very supportive and have an open door.”

There is a system of regular staff meetings in place. Staff meetings were two way and staff raised concerns and points during the meetings. There is a complaints policy in place. Complaints are monitored and action taken to address concerns.

The new manager was a registered nurse and had been at the service for a long time. They knew people and the staff team well. The new manager told us staff were supportive of them and they had a positive working relationship. The prime focus of the manager role had been reviewed and amended slightly to realign the role to have a greater focus on care provision when the new manager came in to post. The new manager was supported by a new deputy manager and the assistant director of care & commercial operations. There was a contingency plan in place which set out what the service would do if there were concerns such as a flood or adverse weather incident.

The new manager told us they kept up to date through linking with organisations such as CQC updates and the local authority registered manager forum. They had supported the previous manager to complete audits, CQC notifications and liaise with safeguarding so had an aware of the appropriate systems and processes. The new manager understood the need to be open and transparent if there was such an incident and understood their duty of candour responsibilities. A duty of candour incident is where an unintended or unexpected incident occurs which result in the death of a service user, severe or moderate physical harm or prolonged psychological harm. When there is a duty of candour event the provider must act in an open and transparent way and apologise for the incident.

Systems and processes to support people and relatives to speak up had been improved. People told us they felt able to raise issues with staff or the manager if they had any. One person said, “I will tell them if I have any concerns.” Another person said, “I did complain some time ago about a member of staff and [management] sorted it out for me.” A staff survey had been completed and a survey for people had now been developed and was being rolled out. Staff met regularly throughout the day to share information with each other and keep each other aware of any changes of developments such as if a person was feeling unwell.

The new manager told us they had an open-door policy and welcomed anyone to come to the office to speak with them. They also had an active presence in the service. A new lead nurse role had been added which was a main point of contact for families and staff. A personalised newsletter service had been introduced that made it easier for families to share news and keep connected. A comment box has been introduced and new surveys for people and their relatives were now available for people to complete. The management team offered relatives the opportunity to meet with them. The Assistant Director of Care & Commercial Operations would also meet with families and told us they felt this had reduced the number of concerns raised as families sometimes just need a chat to alleviate concerns. A survey for staff had been completed and was in the process of being analysed. Staff said managers were approachable.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There was a system or regular auditing in place. This included medicine audits which were completed regularly. Actions plans where in place where improvements were identified by the service as needed. At the last inspection some aspects of staff training were not up to date. For example, not all staff had completed training on how to support someone with a learning disability or autistic people. At this assessment staff training had improved and staff had completed this training. However, there were areas of training still to be completed. Accidents and incidents were documented and checked by the manager, before entering the details into a new incident management system that was currently in development. Root cause analyses was undertaken by the registered manager where appropriate. Trends and patterns were analysed and tracked to promote improvements and minimise further accidents. Notifications were submitted to CQC as required by law.

There was a management structure in place. At the start of the assessment there was a registered manager in place at the service. However, they left during the assessment period. The registered manager had been supported in their role by a deputy manager and a staff wellbeing and training coordinator. After the registered manager left the deputy manager took on the role of manager. The service had recently added the role of lead nurse to the management team to help drive forward improvement such as staff support. Staff were clear about what was expected of them. In the staff survey 93% of staff said they understood what is expect of them in their working role. Other members of the team included, Team Leaders, Care Assistants, activity team, admin team, Chef and kitchen team and housekeeping team.

The service works in partnership with other organisations. For example, the nursing team had recently discussed and reviewed how they communicated with the GP to improve joint working and seek efficiencies. Staff understood people’s needs and were aware of professional guidance such as where people needed support with modified diets.

Feedback from health and social care professionals was positive. Feedback included that staff had responded quickly and positively to professional advice. Health and social care professionals also told us that they felt the service had improved markedly. They found that staff had a very good knowledge of people’s personal needs and preferences.

The GP undertook a weekly ward round at the service. Referrals were made to other health and social care professionals as required. Staff worked alongside other services as needed. Where health care professionals had issued guidance, this was in place for staff. For example, where people needed a modified diet due to issues swallowing.

Feedback from people and their relatives included that they felt people’s health needs were well supported by the service. There was a GP round at the service where the GP visited weekly. One relative told us, “The staff are great they keep me informed of any health issues, they have a good relationship with the Medical practice and mum can be seen when they visit”.