Bridgemead

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• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to required improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The visions and values were located on notice boards within the home, on their website and within a formal strategy plan. Vision reflected the provider’s Christian ethos of, “Supporting and building a Christian community that encourages and supports spiritual wellbeing.”

The provider understood how a poor culture could affect people’s care. However, some staff told us there were ‘cliques’ amongst staff which made the working environment more stressful than it needed to be. Staff demonstrated an understanding of the organisation’s values, aims, and vision.

However, there was a cultural divide among some staff, residents, and relatives following the change in ownership. This division mainly related to operational changes and the shift in organisational culture. Leaders acknowledged the cultural issues and said this was due to differences between the old and new operational models. They recognised that whilst progress had been made, further work was needed, and they were in the process of making plans following the feedback from the assessment of the service.

Leaders did not always embody the culture and values of their workforce and organisation.

Staff and relatives felt they were able to speak with the manager but was not confident issues would be followed through in a timely manner. One person told us, “Neither my (relative) or I are convinced there would be follow through.”

Leaders had not identified the concerns we found in relation to some medicine practices, monitoring people’s outcomes and managing risks for people.

However, leaders were knowledgeable about the issues and priorities for the service and had a service improvement plan in place. The current manager had decided not to pursue their registration with CQC, and the service was in the process of recruiting a registered manager.

The provider did not always foster a culture where people felt they could speak up, and their voice would be heard.

Some people and their relatives said they did not feel able to raise concerns during meetings and did not feel listened to by senior management. Comments included, “We can’t raise issues during meetings, we are shut down,” and “Management are distant and authoritarian.” Leaders told us they were considering ways in which to manage relative meetings going forward. This was due to receiving feedback from some relatives where they felt some of the comments raised by other relatives during meetings were not appropriate.

Most staff said they could speak to the manager, but they could not speak up with senior leaders and if they did, they did not feel listened to. One staff member commented, “I don’t think we can, we don’t feel comfortable talking with the new company, I don’t know what it is, they don’t listen.”

We also saw some staff were not having regular access to supervisions which would have given them the opportunity to speak up. The provider had taken action to ensure staff had access to supervision in the future by putting a schedule in place.

However, the provider organised regular staff, resident and relative’s meetings and there were regular opportunities for people and staff to feedback through surveys. There was a whistleblowing policy, and the provider had not received any whistleblowing concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a legal requirement to run the home as a Christian community due to the charitable objectives. This meant the service qualified for exceptions to the Equality Act 2010. The service manages admissions and employs Christian staff in senior roles to ensure the service remains a Christian community.

Staff were employed at the service from diverse backgrounds. Some staff reported fears about losing their jobs if they did not fit in with the Christian values of the provider, however we found no evidence of this happening. Staff mainly told us Christian and non-Christian staff co-existed in the service, and they worked well together. One staff member commented, “We all work together, there isn’t a division between Christian and non-Christian staff. They don’t expect us to be a Christian to do our jobs.”

There were policies in place to support workforce equality, diversity and inclusion.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Systems and processes were not always effective in identifying and addressing concerns.

We identified the oversight of recording people’s outcomes was lackingin some areas. For example, daily records did not always evidence people’s needs were being met, and governance systems had not identified this. Recruitment checks had not always been carried out, and leaders had not identified this. This meant the provider had not completed checks in line with legislation.

Some staff were not having regular supervisions, although a schedule had since been implemented.

Concerns were also identified in relation to medicines governance, For example, gaps in temperature monitoring for fridges, emollient risk assessments not consistently in place and allergies not consistently documented on MAR charts. These concerns potentially placed people at risk of harm.

However, there were other audits taking place which were effective. The service analysed falls and call alarm bell times. There was a policy in place for the availability, integrity and confidentiality of data, records and data management systems.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

There was evidence of partnership working with other external agencies to improve the care for people. Partners provided feedback about the way the service worked with them and commented on positive impacts when interventions had taken place.

There was an ongoing relationship with a Church located opposite the service. People who were Christians and living in the home said it provided them with a sense of comfort knowing they were living in a home where they could practice their religion.

The provider had established community links with the local Guide Dog Association, Morris dancing group and Bee Keeping Association.

A small number of people noted the lack of arrangements by the service to access opportunities outside of the service. However, some people said they went out regularly with family and friends. Leaders told us they had a minibus available and once the activities co-ordinator commenced in their role there would be more opportunities available to access the community.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider had purchased a new case management system to capture people’s information and track people’s outcomes to improve the systems and processes in place.

Due to the location of the building, there was a risk of flooding, and this had happened in the past. The provider had commenced flood defence work on the service to ensure sustainability for the future and to keep people safe.

Building work was being completed on outdoor spaces for the long-term accessibility of residents. They had also started a refurbishment plan inside the building. The refurbishment work taking place was being completed in a considerate way, so it did not have a negative impact on people living in the service. People living in the refurbished rooms were happy with the results.

Leaders wanted to continuously improve the service for people and to ensure they had a good experience of living in the home. Leaders listened to the CQC assessment feedback to understand the concerns people and staff said about the service. Leaders said they would consider the changes they needed to make to move forward cohesively with staff and people.