Bridge House

Bridge House is a 'care home.' People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The CQC regulates both the premises and the care provided, both of which we looked at during this inspection.

At the last inspection on 18 April 2016, the service was rated good. At this inspection, we found the service had improved to outstanding.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was exceptionally well-led. All staff showed a passion and commitment to providing the best support to enable people to have full lives. The management team and staff shared common values about the aims and objectives of the service. These were based on people being supported to live full and enjoyable lives and engaging with the community they lived in to reduce social isolation. Regular quality audits and checks were completed so improvements were continually recognised and there was effective follow up action which made sure people received a high-quality service.

People at Bridge house received exceptional person-centred care and support. The management and staff team understood what was important to people living at the home and acted upon this to improve people’s quality of life. Management and staff worked closely and with people and their families to ensure each person lived as good a life as possible. People played an active part in the running and development of the home. A motivated management and staff team came up with new ideas to enhance people's quality of life and provide benefit to people.

People were supported to retain an active presence in the local community and to maintain their personal interests and hobbies. An activities team alongside care staff all worked together to organise an imaginative and rich programme, providing every opportunity for people to take part in activities that were meaningful. People had opportunities to maintain and develop relationships with visitors to widen their social networks. There was a sense this was people's home which people were proud of. People were supported to actively use their skills and interests in the decoration of the different spaces within their home environment.

Food and drink were provided to a high standard and people could choose what to eat and drink, as well as decide on times of their meals. People who lived at the home and their relatives could voice their views and opinions. The registered manager listened to what people had to say and took action to resolve any issues. The management team reviewed incidents and concerns to look for opportunities to improve policies and practices for the future. There were systems in place for handling and resolving complaints which focused upon opportunities for learning lessons.

People who lived at the home and all staff were actively encouraged to contribute to the evaluation of the care and support provided and make recommendations for improvement. The management team and staff worked together as a team with a passion to learn about and aim for best practice, with people very much at the heart of the services they received in their home.

People were supported to make safe choices in relation to taking risks in their day to day lives, which helped people to maintain their own levels of independence. This was because staff made sure people had the equipment and aids they required to meet their needs. Staff had been suitably trained and understood how to support people in a way which protected them from harm and abuse. People benefited from positive risk taking which improved their morale and quality of life.

Staff received regular training which provided them with the knowledge and skills to meet people's needs in an effective, responsive and personalised way. The management team supported staff to gain additional knowledge to promote a greater awareness and understanding of the diverse needs of people whom they provided with care and support. Staff had used their knowledge in practice on many occasions to support people in gaining additional equipment, aids and specialist advice which had a significant impact on enhancing people's well-being.

The service worked in partnership with other health care organisations, local school and a local hospice. The registered manager provided free of charge training for other health care providers and pioneered a toddler group that was interacting with people living in the home.

At a comprehensive inspection of this service in January 2015 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds with two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to people not being protected from the risk of infection as well as people’s records not being current and accurate. At this inspection in April 2016 we found the required actions had been taken. We found improvements had been made at this inspection. People were protected from the risk of infection and their records were current and accurate.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager worked closely with the business and clinical manager.

People who were supported by the service felt safe. Staff understood how to safeguard the people and protect their health and well-being. People’s medicines were stored safely and people received their medicines as prescribed.

There were enough suitably qualified and experienced staff to meet people needs. However, there was poor staff engagement with people. The registered manager had recently recruited new staff who were still undergoing the provider’s induction programme.

People had a range of individualised risk assessments in place to keep them safe and to help them maintain their independence. Where required, staff involved a range of other professionals in people’s care.

People received care from staff who understood their needs. Staff received adequate training and support. People felt supported by competent staff. Staff benefitted from regular supervision (one to one meetings with their line manager) and team meetings.

The registered manager and staff had a good understanding of the Mental Capacity Act 2005. Where people were thought to lack capacity, assessments in relation to their capacity had been completed in line with the principles of MCA.

The registered manager and staff understood their responsibilities under the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.

People’s nutritional needs were met, however the dining experience varied. Staff did not always speak with people during meals. People were given choices and received their meals in timely manner.

There was a calm, warm and friendly atmosphere at the service. Staff we spoke with were motivated and inspired to give kind and compassionate care. Staff knew the people they cared for and what was important to them. People's choices and wishes were respected and recorded in their care records.

Where people had received end of life care, staff had taken actions to ensure people would have as dignified and comfortable death as possible. End of life care was provided in a compassionate way.

People had access to a variety of activities and stimulation from staff in the home, however, these were not always structured to people's interests.

People told us the management team were open and approachable. The provider had quality assurance systems in place. The provider had systems to enable people to provide feedback on the support they received.

The registered manager informed us of all notifiable incidents. The registered manager had a plan to develop and improve the home. Staff spoke positively about the management and the direction they had from the registered manager.

On the day of our visit 56 people were using the service. They were supported by two nurses and twelve care workers. We briefly spoke with 12 people who used the service and three people's relatives and friends. We also spoke with five care workers, two nurses and the manager. Two inspectors carried out this inspection.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

The service was not always safe. The provider did not always have systems in place to ensure people's medicines were administered safely or recorded appropriately. The service maintained records of the stock of people's prescribed medicines but these were not always accurate.

Is the service effective?

The service was not always effective because people's needs were not always being met. Care workers did not record incidents where people were agitated. Staff did not look to see what caused this agitation to improve the person's care.

People's care plans did not always contain current guidance for care workers on how to meet people's needs. This meant that people could be at risk of inappropriate care or treatment as an accurate record of their care needs had not been maintained.

People were protected from the risks associated with malnutrition, falls and moving and handling. Care workers demonstrated a good knowledge of people's care needs.

Is the service caring?

The service was not always caring. We found that people could not always be sure they were treated with dignity and respect. Staff did not always promote people's privacy.

We saw that often people benefitted from kind and caring care workers. We conducted short observational framework for inspection (SOFI) observations throughout our visit. We observed that people were often treated with respect.

We considered our inspection findings to answer the questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

Is the service safe?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety. We looked at seven care records. Care plans were regularly updated and appropriate risk assessments were in place. We looked at the care records for people who had been assessed as at risk of choking. They had been referred to a speech and language therapist (SALT). Their care plans and risk assessments reflected the recommendations made. These included thickening fluids to a single cream consistency. The care workers we spoke with were able to describe how people should be supported

Nurses told us that they had recently been trained in administering medicines and had their competencies assessed. We observed part of the morning or lunchtime medicines round on each unit and found that medicines were safely administered. For example, we observed the staff member who administered medicines wore a tabard to identify their role and was not disturbed by other care workers while medicines were administered. People's medicines were prepared and administered individually, helping to reduce the risk of errors.

Is the service caring?

During the SOFI observation we observed a person who was in bed. Throughout the observation we noted that care workers frequently looked into or went in to check if the person needed assistance. At times care workers stayed for a few minutes chatting to the person without performing any care tasks. On other occasions the person was assisted to drink or change position. Throughout our inspection the atmosphere was pleasant and we observed many interactions between care workers and people that were caring, relaxed and friendly. This meant that people received appropriate care and benefitted from good interactions with care workers.

Since our last inspection the home had employed a number of new staff including dining room assistants. We spoke to people and asked them if they felt there were enough staff to meet their needs. One person told us 'things have really improved'. Another person said the home was 'absolutely wonderful, staff are kind'. A relative told us 'staffing levels have improved enormously'. Staff told us the dining room hosts had been a positive addition to the team.

Is the service responsive?

Some people were prescribed medication for only when needed (known as PRN medication) for example, paracetamol. We observed a person being given pain relief promptly when they asked for it. The nurses checked how often people were having medication that was prescribed for only when needed. If required a review with the GP was arranged in case the person needed pain relief as a regular dose throughout the day. People we spoke with told us that any requests for pain relief were responded to promptly. One person told us 'I tell the nurse if the pain is severe' and that it was 'responded to immediately'. This showed that the home was responsive to people's needs and people had medicines at the times they needed them.

From our observations we saw that staff responded in a timely manner to call bells. We observed care on all three units and saw that care workers did not rush people during care tasks. We noted that although care workers at times were busy there was a calm and pleasant atmosphere throughout the home.

Is the service effective?

There were arrangements in place to deal with foreseeable emergencies. For example, there was emergency lighting and plans for managing the person's needs in the event of a power failure. We saw that each care record also held an emergency evacuation plan for use in the event of a fire. This plan was detailed and personalised which meant people could be assisted to leave the premises in the most appropriate way according to their moving and handling needs.

Care and treatment was planned and delivered in a way that was intended to ensure people's welfare. We saw that care planning took into account the needs of the person as a whole. This included information ranging from their health needs such as tissue viability, moving and handling and their dietary needs, through to their social, religious and spiritual needs. There was a choice of activities organised, run by a dedicated activities co-ordinator. One person told us that the activities co-ordinator was 'incredibly good' and told us about how they had been supported to arrange a film evening for a group of people. Another person said 'I go to things that interest me; there is always plenty to do'.

Is the service well led?

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. For example, during a residents and relatives meeting it had been identified that some people would like alternative options on the menu. We spoke with people about this, they told us 'we have a residents meeting once a month', 'we can raise anything' and 'we asked for there to be different menu choices. The menu has been adapted with what we suggested'.

We spoke with the manager who outlined the range of quality monitoring systems in place to review the care and treatment offered at the home. These included a range of clinical and health and safety audits, monitoring of peoples feedback and reviews of all accidents, incidents and complaints. We saw evidence of how the quality monitoring systems were used to make improvements to the home.

We spoke with 13 people who used the service and three people's relatives. One person told us 'the carers are wonderful and the care is good. The food is not so good. There is not much choice. If it is Monday it's sausages, that sort of thing'. Another said 'I like it here, the girls are lovely. The food varies but I feel well cared for'.

We found that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People were offered a range of appropriate and meaningful activities.

On the day of our visit, there were 45 people living at the home and nine care workers on duty. This included two nurses. We were told that the deputy manager and manager were also nurses and worked clinically where extra help was required. There was also a range of other staff employed by the home such as main kitchen staff and domestic assistants. We found that there were not enough qualified, skilled and experienced staff to meet people's needs. Care workers appeared rushed and people we spoke with told us they felt their call bells took a long time to be answered. One person told us 'you have to wait ages; they answer the bell when it has been ringing for ages and say they will come back but that takes ages too'. Care workers we spoke with also told us they undertook additional roles such as serving meals, washing up and tidying the kitchen which reduced the time they could provide care to people.

Staff told us they felt well supported in their roles. People told us that staff were knowledgeable and knew what to do for them. We saw evidence that the provider had provided opportunities for care workers to obtain further relevant qualifications.

In this report the name of a registered manager appears, who was not in post and not managing the regulated activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

We spoke with four people who used the service and one relative. At the time of our visit, 21 people lived at the home. Everyone we spoke with were highly complementary about the home. One person told us, "I couldn't wish for better care, a better place or better people. The care staff are very friendly and helpful and nothing is ever too much trouble'.

Care workers and other staff were supported appropriately. We found that arrangements had been made for staff to receive supervision regularly. We spoke with six members of staff and looked at six employee files. All staff had received regular supervision and an appraisal.

We looked at eight care records and saw that following our visit the provider had introduced new streamlined documentation and provided care plan training for staff. An audit of care plan documentation had taken place to check on the quality and accuracy of records and any deficiencies were highlighted to the appropriate staff member to remedy.

We spoke with five people who told us they were happy at the home. One person told us, 'This is a very nice place. I get enough food and drink and the carers are good'. Another person told us, 'The staff here are excellent'.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Appropriate checks were undertaken before staff began work. Ten personnel files were looked at.

Care workers and other staff felt that support and communication systems could be improved.

People who used the service, their representatives and staff were asked for their views about their care and treatment, and they were acted on. We saw records of complaints that the provider has received since the service opened.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.