Date of Assessment: 10 June 2025 to 25 June 2025. The service is a care home providing nursing care. The service provides support to adults of all ages living with dementia and nursing needs. The service was identified for an assessment due to information received from the local authority and notifications to CQC. Systems and processes were not effective in identifying health and safety, infection control and medication concerns. People’s privacy and dignity was not always respected. Care plans and risk assessments were detailed and person centred. The provider and management teams were responsive to our feedback both during and after the assessment. During this assessment we found breaches in regulation. We found breaches in Regulation 10 (Dignity and respect), Regulation 12 (Safe care and treatment), and Regulation 17 (Good governance) in the service. Whilst people and relatives were positive about the quality of their care, this did not reflect the evidence we found during our assessment. People told us they felt safe, one person said, ‘I feel very safe, I enjoy living here, the staff are lovely’. People were aware of how to raise a complaint and felt confident in approaching leaders. We observed people were comfortable with their staff. People provided feedback on how the home met their care and health needs. One relative told us, ‘They look after [Relative] well, they can at times not want to join in, but they try’.
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Bradeney House achieved an overall Good rating at its November 2023 inspection, with Safe and Responsive both rated Good, but Well-Led dropped to Requires Improvement due to weaknesses in governance, inconsistent record keeping, and insufficient monitoring of call bells, mealtimes, and care plan quality. The registered manager demonstrated responsiveness to concerns raised during inspection, and no regulatory breaches were identified.
Concerns (6)
moderateRecord keeping: “We found gaps in various records during the inspection process which made it difficult to establish what actions had or had not been taken.”
moderateGovernance: “The providers systems did not always effectively monitor the quality of the care provided to drive improvements.”
moderateCare planning: “The provider's electronic care planning system had limited their ability to create bespoke care plans for health conditions such as, diabetes.”
minorMedication management: “The guidance was often generic stating 'give for agitation' without describing what agitation looked like for each individual.”
minorIncident learning: “More robust recording of the outcomes was needed. We noted on accident and incident forms not all the areas were completed after an incident.”
minorPerson-centred care: “People raised some concerns about call bells and the mealtime experience, these areas were not being effectively monitored.”
Strengths
· People were safeguarded from abuse and avoidable harm; staff trained in recognising and reporting abuse annually.
· Sufficient staffing numbers maintained with safe recruitment processes including DBS checks.
· People were supported to have maximum choice and control in the least restrictive way in line with MCA.
· Provider worked in partnership with GP surgery and external professionals, with positive feedback from visiting professionals.
· Strong family liaison role supporting communication and complaints resolution.