Bourne Bridge House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe premises and equipment.

This service scored 62 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager promoted an open and reflective culture. Safeguarding and staff practice were regularly discussed. Oversight arrangements included audits, spot checks and monitoring of incidents to identify any themes and areas for improvement.

Staff told us they would report any poor practice and were confident concerns would be acted on. They were also able to describe signs that a person may be at risk of harm, particularly where people communicated non-verbally and changes in personality could indicate something was wrong.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People's care records contained detailed information to guide staff and support consistency of care. Staff knew people well and understood their preferences and support needs. Where people required support to attend appointments or access services in the community, staff shared relevant information to help ensure support remained consistent.

Staff worked with healthcare professionals, advocates and other agencies when needed to help ensure people received coordinated support. Staff told us they sought specialist advice when changes in people's needs were identified, particularly for people who may have difficulty expressing concerns or communicating changes in their wellbeing.

One professional told us; “They (staff) have a good relationship with the learning disability team and will escalate concerns to them or myself as appropriate.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had received training in how to safeguard people. Staff we spoke with were confident to report concerns and satisfied action would be taken to investigate them. Staff told us, they would raise concerns immediately if they witnessed poor practice. One staff member said they would, “Report it straight to the manager and ensure action was taken.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff demonstrated an understanding of the Mental Capacity Act 2005 (MCA) and ensured any decisions made for individuals who lacked capacity, were consistently made in the person’s best interest. Staff completed training and could clearly explain how the principles of the MCA applied in their daily practice. Staff described how they supported people in the least restrictive way possible, encouraging them to make informed choices about their care and daily routines.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Environmental risks were not always identified or addressed in a timely way. During the inspection we observed a number of concerns that indicated potential risks to people were not managed safely or proactively. This included the storage of COSHH items (Control of Substances Hazardous to Health) in an unlocked cupboard outside. In addition, we saw other potential risks in the environment that had not been managed promptly by staff to keep people safe.

Some risks to people were managed by implementing restrictions in the environment. These included keypads on doors to prevent people going into the kitchen unsupported by staff, and were documented within the provider’s Environmental Risk Assessment. The restrictions were also reflected in individual DoLS authorisations where appropriate, however improvements were required to strengthen the recording of whether the restrictions were the least restrictive option.

People had care plans and risk assessments with guidance for staff on techniques and strategies to use when responding to incidents. These were reviewed with the relevant people. This included Positive Behaviour Support (PBS) plans. These are plans that enhance people’s life while reducing the likelihood of distressed behaviour. Staff we spoke with were able to tell us how they supported people when they were distressed.

People’s relatives told us staff managed risks well to keep their loved ones safe. A relative told us, “I have no concerns, if there is a problem staff deal with everything, staff are very good at deescalating should a situation arise. I find all staff and management to be open and honest, and experienced to deal with [person’s name] needs and requirements.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.The environment was not consistently safe, well maintained or fit for purpose.

We identified a number of environmental and premises-related concerns that placed people at risk of harm. These included a curtain rail hanging from a bedroom wall, a front door that did not close properly due to a broken hinge, a loose radiator cover and an unsuitable light pull cord comprising string with a metal object attached. One flat had a persistent smell of damp throughout, and although dehumidifiers had been provided to mitigate this risk, staff had not ensured they were in use.

People were exposed to avoidable risks associated with slips, trips and falls, injury, and the potential health effects of prolonged exposure to damp and mould. The failure to take timely remedial action meant we could not be assured that people were consistently living in an environment that was safe, comfortable, well maintained, or fully supportive of their health, wellbeing and dignity.

These concerns demonstrated that systems for identifying, escalating and addressing environmental risks were not always effective. Although the registered manager had identified a number of environmental issues requiring improvement through their oversight and monitoring processes, the provider had not taken prompt action to rectify these concerns. This meant known risks remained present within the service for longer than necessary, increasing the potential for harm and negatively impacting people's living environment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager ensured there were adequate staff employed to meet people’s needs. Safe recruitment practices were in place to ensure suitable staff were employed. The registered manager hadobtained Disclosureand Barring (DBS) checksbefore new staff started employment.New staff completed a full induction process as well as completion of their mandatory training and competency checks to ensure they had the knowledge and skills to undertake their duties. Staff undertook regular refresher training to ensure their knowledge stayed up to date with best practice guidance.

One professional told us; “I see that staff actively advocate for patients’ needs and are proactive to ensure adequate care is received. The interactions I’ve had with my patient in front of staff are positive and I see they try to be flexible and accommodate people’s needs, while keeping them safe.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The provider failed to adequately assess, monitor and mitigate risks relating to infection prevention and control. During the inspection, we found multiple infection concerns, including mould around baths and shower trays, persistent damp conditions and a strong smell of damp within one person's flat.

Damp, mould and the deteriorated condition of parts of the environment prevented staff from being able to clean some areas effectively and maintain appropriate standards of environmental hygiene. As a result, there was an increased risk of infectious agents persisting and spreading within the environment. The poor conditions had not been effectively escalated, remedied or adequately managed, placing people at unnecessary risk.

People were therefore living in an environment where effective cleaning and infection prevention and control measures could not consistently be maintained, increasing the potential risk to their health and wellbeing.

The provider had not taken sufficient action to detect, control and reduce these risks, meaning people could not be assured that appropriate measures were in place to protect them from avoidable harm. Poor infection prevention and control practices can be particularly detrimental for people with existing health conditions, compromised immune systems or respiratory illnesses, who may be more vulnerable to environmental hazards. In addition, the ongoing presence of damp and mould risked negatively impacting people's physical health, comfort and wellbeing, while the failure to promptly address these concerns demonstrated a lack of effective oversight.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely, with staff demonstrating the knowledge, skills and competency required to administer, store and record medicines effectively. People received their medicines as prescribed and medicines records were completed accurately. Where people were prescribed medicines to be taken on an 'as required' basis (PRN), clear protocols were in place to guide staff. These included detailed information about when medicines should be administered and alternative, non-medicinal strategies to be considered before the use of PRN medicines.

Medicines were reviewed regularly, and detailed support plans were in place to ensure people's individual needs were met safely and consistently. The service had effective systems for monitoring medicines management, including regular audits and checks, which helped to maintain safe practice and identify any areas requiring improvement.

The provider worked in line with the principles of STOMP (Stopping Over Medication of People with a Learning Disability, Autism or Both), supporting the appropriate use of medicines and ensuring people's behaviours of distress were not managed through unnecessary or excessive medication. Systems were in place to monitor the effectiveness of medicines, identify potential side effects and ensure prescribing remained appropriate to people's needs.

Feedback from relatives and professionals was positive. One relative told us, "I've not heard of any medication mistakes. When I pick them up, they're very careful when getting it ready and I sign for it."

A healthcare professional said, "Considering how complex the pharmacological regime can be for many people in care, I feel they do their best to adhere to safe practices, while reporting to me efficacy, changes in medication compliance, and emergence of side effects."

Feedback from relatives and professionals demonstrated confidence in the service's medicines management processes and the staff's ability to support people safely with their medicines.