Bridge House Residential Home

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 requires improvement. At this assessment the rating has remained 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 remained in breach of legal regulation in relation to staffing and the environment.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Clinical and health care reports were developed as part of the quality review process. Newsletters were developed outlining discussion points relating to areas of clinical practice or themes identified. Information included links to best practice guidance and details of relevant agencies. We found newsletters were informative and provided helpful points for staff to be aware of. Managers said staff had acknowledged and signed to say they had read the information. However, due to the instability in management, infrequency of team meetings and supervisions we were not assured how any learning was checked to evidence practice was being embedded and outcomes for people were improved. One staff member told us, “I would prefer this to be provided face to face rather than emails and newsletters."

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 service also worked closely with the local GP, who carried out weekly visits to the service and would make referrals to other healthcare teams where necessary. Staff said the GP was supportive and accessible.

Prior to people being placed at the home assessments had been completed to determine if their needs could be met. The gathering of information could be improved with the involvement of people and their relative, where appropriate.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

At this time the local authority are not placing people at Bridge House. Both the local authority safeguarding and quality teams continue to monitor and support the service, helping to address issues raised with them.

We reviewed information in relation to accident, incidents and safeguarding concerns. We found action logs had not been completed detailing what action had been taken and the outcome to help minimise further incidents. This information helps to identify any themes or patterns so that appropriate action can be taken and any learning shared with the team.

We again reviewed information for those people deprived of their liberty (DoLS). A review of the DoLS tracker showed 17 people were either subject to a DoLS or an application had been made to the supervisory body. We again found notifications informing CQC of the restrictions in place had not been submitted as required by law. It was felt the absence of a manager and effective monitoring systems had impacted on timely and appropriate action being taken.

Feedback from people and their relatives was mixed. Comments included, “I have all I need here”, “Not always safe. The managers are always leaving which is very worrying” and “Safe enough I suppose, it was okay there but it seems to have gone downhill.”

Policies and procedures were in place to help protect people and uphold their rights. Training records showed most staff had completed training in safeguarding, Mental Capacity Act and the deprivation of liberty safeguards (DoLS).

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.

People’s records identified areas of risk to their health and well-being. Plans detailed the level of support required and any equipment needed to help minimise such risks. Additional records were completed to monitor any changes, such as repositioning and skin integrity and weight loss. We were shown an easy read guide had been developed in relation to pressure care and falls. This was to be shared with staff in the flash meetings to help increase knowledge and understanding.

Records showed people at nutritional or choking risk had been seen by the dietician or speech and language therapist. We noted a quick guide displayed should a choking emergency arise. This referred to the use of a ‘dechoker’ and how to use it. However, we saw no information within training records this had been demonstrated to staff to help familiarise them in how it should be safely used.

Incidents such as falls were recorded, including the immediate actions taken at the time. However, there was no information demonstrating what follow‑up actions were implemented when individuals experienced repeated incidents. For example, we noted that one person had fallen multiple times over recent months, yet there was no evidence that a referral to the falls team had been made to obtain additional advice or support.

Specific equipment was in place to aid people’s movement around the home. This included the use of a hoist and wheelchair. People’s relatives said they had observed people being moved and had no concerns. One person told us, “My [relative] is hoisted and I’ve seen them hoist other residents when we are there and everything is fine, people are ok with it.”

Whilst looking around the home we noted call bells were not available in each of the bedrooms. Sensor mats were used as a mechanism to alert staff if people got out of bed. We saw this was an action identified on the provider action plan issued after our last inspection. Risk assessments had still not been completed to determine the most appropriate support mechanism, with the rationale clearly documented in people’s care plan.

A review of the in-house audits, which had recently been introduced showed areas of risks had yet to be reviewed, such as, moving and handling equipment, falls and weight loss. We were told following our visit the new manager had reviewed the equipment in place for people. They had identified further equipment was required, such as call bell leads, additional slide sheets to help safely move people as well as shower equipment.

Environmental checks to the premises and equipment were carried out. A recent fire risk assessment had been carried out, action required to improve fire safety was being addressed. This is also referred to further in this report under the safe environment section.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Bridge House provides spacious accommodation. Aids and adaptations had been provided to meet people’s physical care needs. During our last inspection in July 2025, we identified improvements were required to enhance the physical environment as well as providing a more dementia-friendly environment. An action plan was received from the provider. This stated, ‘A documented programme of redecoration should be developed to address environmental concerns, incorporating residents’ views and preferences’. During this assessment we found no evidence this had been explored and the views of people we sought confirmed this. One relative said, “I don’t go to his room because it is so depressing.”

A further action stated, ‘Dementia friendly signage to be in place to assist with orientation around the building for service users living with dementia’, with a completion date of November 2025. This had not been done. Signage was received during one of our visits.

Whilst looking round the home outside areas had been cleared and the guttering cleaned. However further work was required internally. The ground floor toilet, close to communal areas was not accessible to people, a further toilet and bath were also unavailable. We observed heavy duty locks being fitted to the doors of empty bedrooms. We queried if this was due to the key locks being broken. No response was provided.

We were told the provider had undertaken an environmental audit during a visit to the home on the 1 February 2026. We were told an external organisation had been appointed to conduct a full independent environmental audit. A formal report was to be produced, and recommendations implemented within agreed timescales. A sample report was seen, showing potential options. A copy of the plan for Bridge House was requested, however at the time of writing the report regarding this had not been received.

Records were in place to show the servicing of mains supplies and equipment had been carried out. Internal checks were undertaken. Records identified where faults or repairs had been noted, such as batteries required for emergency lighting, wardrobes not secure, bedroom lighting not working, heating off in bedrooms and no room temperature checks. However, confirmation work had been carried out was not reflected in the records. Following our visit, we were told these had been addressed. Accurate complete records should be maintained to reflect timely and appropriate action has been taken to help keep people safe. We also found defects were identified in relation to fire doors. This too had been identified on the recent fire risk assessment. Work was scheduled for completion.

An up-to-date fire risk assessment had been completed in February 2026 and 10 action points had been identified. Senior managers were aware of the work required ensuring the home was kept safe. Internal records were reviewed to check fire safety checks and drills were undertaken. A poster was displayed advising fire drills were held every Thursday. Whilst records showed drills had been carried out these did not include all members of the day and night staff team. This was important so staff were aware of the evacuation procedure in the event of an emergency. Training records showed annual fire awareness training was provided. We found 6 staff had yet to complete or update their training.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Pre‑employment checks were completed before new staff started work, which helped ensure individuals were suitable for their roles. However, we found no evidence of values‑based interview records, despite this being required by the provider’s policy.

We again found limited evidence of meaningful induction or supervision taking place, also set out within the home’s policy and procedures. We were told and staff confirmed recent supervision meetings had been held. A review of records did not evidence any meaningful discussion with the staff about their role. Managers agreed for this to be incorporated going forward. We also noted induction training provided for new staff was again covered within a 2 or 3 days period. This was not line with policy or best practice.

Staff had access to both e‑learning and face‑to‑face training. Staff spoken with confirmed training was provided. A review of the training matrix showed one staff member, who had recently changed role, had yet to complete the majority of e-learning. Other training updates were required for some staff and additional training was needed for kitchen staff. One staff spoke positively about recent face‑to‑face training they had attended. However, there were no records to show which staff had completed face‑to‑face training. Following our visits we were advised by the local authority the new manager had identified further training needs within the staff team.

We received a mixed response from people and their relatives about the skills of staff. Relatives told us they felt staff would benefit from further training to strengthen their skills in supporting people living with dementia. One relative spoke about the care of their family member, adding, “Well I don’t think they are trained in dementia.” Other relatives said, “I don’t see much of the care but [relative] is kept clean and always looks tidy” and “[Relative] can be very difficult at times, the staff cope with it well.”

We reviewed the staffing arrangements within the home. It was unclear from the rotas how staff were deployed throughout the day and night. From our observations we saw staff were busy yet attentive when supporting people. People’s relatives felt staff were not always present and more care were required to effectively meet people’s needs. Comments included, “Staffing is a real problem. I go in and often I don’t see any members of staff”, “Hardly ever see a member of staff” and “They have a lot of agency staff and that’s not good for people, so many different faces. No consistency around staffing.” We were told a recent change had been made with an increase in evening staff.

The provider used a dependency tool to calculate appropriate staffing levels. This tool focused on people’s physical and cognitive needs. It was unclear how the scoring criteria had been applied, and the assessment did not consider people’s social or emotional needs. We were told further appointments had been made with regards to activity and maintenance staff. They had not commenced employment at the time of our visit.

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.

Policies and procedures and areas of training were in place to guide staff in infection prevention and control and food hygiene. We noted refresher training was required for a number of staff in infection control.

Designated staff were responsible for the cleaning of the home each day. Staff wore personal protective clothing when assisting people with aspects of their care. Items were cleaned away and disposed of properly. One person told us, “The place is generally quite clean.”

A recent audit had been undertaken by the local authority health protection team. A 94% compliance result had been achieved. A food hygiene inspection had also been undertaken in September 2025, the service was awarded a hygiene rating of 5, very good.

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.

People received their prescribed medication safely. Policy and procedure were in place for the safe management and administration of people’s medicines. Staff responsible for the administration of people’s medicines had completed relevant training.

Medicines administration records were completed. Records included a pen picture of the person, information about the persons medication and approaches in areas of care. Plans were in place to guide staff for those people who required time critical medicines or medication on a ‘when required’ basis. Where people received their medication covertly (in food or drink), a best interest decision had been made together with the GP. People’s relatives said they were kept informed about changes in medication.

Suitable arrangements were in place for the safe storage of controlled drugs. A random check of stocks was completed. These corresponded with records held. Additional records were maintained for topic creams and the use of thickening agent. We were told lock boxes were being put in place so people’s creams could be stored safely in their rooms.