Bridgewood Mews

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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Accidents and incidents were recorded by staff and, where applicable, were reported to relevant external healthcare professionals. They were also reviewed and analysed for understanding and learning.

A learning culture was also evident in how audit action plans and complaints were used by leaders to develop continuous improvement. For example, the provider communicated issues that had been identified in audits and shared learning with staff within team meetings.

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.

The provider ensured safe systems of care in relation to the transition process for people before they moved to the service. Leaders told us this process consisted of obtaining information about people’s needs by completing assessments of people, and this information being used to develop people’s care plans and risk assessments. Records we reviewed supported this.

As reported elsewhere in this report, effective systems were also in place to ensure: safety events were analysed for understanding and learning; safeguarding and Deprivation of Liberty (DoLS) procedures were clear and followed. Care plans and risk assessments contained clear, relevant and updated information about people’s needs. The service worked well with external professionals; people’s mental capacities were assessed and recorded, and, where possible, consent sought from them; and staff were provided with clear and effective support from leaders.

However, effective systems were not in place to ensure people and/or their legal representatives where applicable, were involved in developing and reviewing their care plans.

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.

There was a safeguarding policy in place, records showed staff had completed safeguarding training and staff were able to tell us the action they would take if they had concerns. Leaders also told us how safeguarding concerns would be reported to the local authority and CQC, and we saw information in care records which demonstrated this.

We were informed people felt safe at the service. One person told us, "Staff make me happy”; while relatives said people were safe at the service, with 1 relative saying, “Staff are absolutely great with [my relation]; they protect them.”

The service ensured people’s mental capacity was assessed relating to aspects of their care. 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 and found people had up-to-date DoLS authorisations in place.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments contained relevant information about people’s care and health needs. For example, care plans and risk assessments were clear, detailed, person-centred and provided up-to-date information about people’s needs.

Although not all staff had competed all relevant training about people’s needs, the information staff told us about people demonstrated a clear and thorough awareness of their needs. This was supported by our observations of how staff supported people, such as with their communication, mobility and emotional needs.

Relatives told us staff knew people’s needs, with 1 relative saying, “They know [relation]. They have done a lot to minimise risk for them.”

Furthermore, leaders also demonstrated good awareness of people’s needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment and facilities supported the delivery of safe care.

The environment was clean and well-maintained. Arrangements were in place to monitor the safety and upkeep of the premises, which included the undertaking of environmental and equipment checks.

The atmosphere and appearance of the home was homely, and people appeared comfortable and relaxed in their surroundings.

The provider did not always make sure there were enough qualified and skilled staff. They did not always make sure staff received regular supervision.

The recruitment records we viewed did not demonstrate safe and robust recruitment practices were always carried out. For example, where staff had been recruited without a Disclosure and Barring Service (DBS), they did not always have a risk assessment in place which detailed how the service would mitigate this risk. This could place people at risk of receiving care from unsuitable staff. We fed this back to the provider who advised they completed a risk assessment and advised the member of staff was not working at the service until their DBS was returned.

People were not always supported by appropriately trained staff. The staff training matrix showed staff were trained in several areas to support people safely, however we found staff had not always received training in specific health conditions relevant to people’s needs. For example, although there were people who received support for dementia, Parkinson’s disease, epilepsy, percutaneous endoscopic gastrostomy (PEG) and skin care needs, there were some staff who had not received training in these areas, with some staff also telling us this was the case. We fed this back to the provider who advised us they had arranged further training to ensure staff were appropriately trained in all areas.

Records failed to show staff received regular supervisions from leaders over a sustained period of time, the provider advised a change in the system caused this documentation issue and staff did receive regular supervisions. Feedback we received from staff supported what the provider told us, therefore we determined this was a documentation error and concluded staff were well supported in their roles.

The staffing levels we observed reflected the staff rota, which was consistent and in accordance with the service’s dependency assessment tool.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and tidy, staff wore appropriate protective personal equipment (PPE) when supporting people to help protect them from avoidable infections and staff completed infection prevention and control training.

Relatives told us they were happy with standards in the service, with 1 relative saying, “[Relation’s] bedroom is always clean.”

Leaders informed us of the systems in place to ensure the risks of infection was minimised. This included the provision of multiple PPE stations within the home, checks and audits of infection prevention and control areas.

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.

Staff received training in safe medicines management and staff we spoke with demonstrated good awareness of medicines processes and people’s individual medicine needs.

Clear systems and processes were in place regarding the storage, administration and documentation of people’s medicines, and we observed medicine stock counts were accurate which indicated people were being supported to take their medicines as prescribed.

People who took their medicines covertly had records which showed the decision had been made in their best interests and the decision was reviewed on a regular basis. Furthermore, there was clear guidance for staff on how such medicines needed to be given to people.

Leaders told us how they used an electronic medicine system to monitor medicine practices, and they also completed regular medicine checks and audits to ensure safe and appropriate medicines practices. When we reviewed medicine audits, we found these were being used effectively to identify and improve standards in this area.

Relatives were happy with the medicines support their relations received, with them telling us, “[Relation] gets all of their medicines”; and “Staff give [relation] all their medicines and that keeps them safe here.”