Bridge House Residential Home

On this page

• 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 requires improvement. At this assessment the rating has remained requires 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 remained in breach of legal regulation in relation to governance at the service.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

A new manager had been appointed and was due to start work after our visit. It was expected the new manager would work closely with staff and other stakeholders to make the improvements needed in the home. For the home to succeed, it is important to have a stable leadership team that sets a good example and creates an inclusive culture where everyone feels valued.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service has been without a registered manager for over 3 years. Members of the senior management team had been supporting the home. Whilst management appointments had been made, these had not been successful in providing stable and consistent management and support for the team.

Staff spoken with, expressed the need for permanent and consistent management as continual changes and different approaches had impacted. This was also supported by people relatives who said they were unaware of the management arrangements and the impact on staff. Relatives told us, “The staff suffer from no management and a lot of agency staff”, “Lots of different managers during the year, last one only stayed a few weeks. No idea who it is now or if there is one” and “The most recent manager has left. Managers don’t stay."

People did not always feel they could speak up and that their voice would be heard.

The provider had a whistleblowing policy. Whilst, some staff felt able to speak up. Regular team meetings and individual supervision sessions had not been provided giving staff the opportunity to share their views and ideas.

A recent staff survey had been carried out. We saw responses were mixed, whilst some staff expressed no concerns regarding their work. Others expressed the need for improvement in areas such as communication and support.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policy information and training on equality and diversity were available to staff, which promoted equal opportunities, including how people’s protected characteristics would be respected. Staff employed under sponsorship arrangements told us they felt supported and included within the team.

Staff said there were systems in place to keep them informed. Information was shared during daily handovers. However, they told us team meetings had been infrequent. Records showed the last staff meeting took place in September 2025, with another planned following our site visits. Staff expressed hope that the appointment of an additional manager would strengthen communication systems, helping them feel more included and involved.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We were not assured effective systems were in place providing clear management and oversight of the service to help drive improvement. Following our last inspection the regional manager submitted an action plan detailing areas for improvement covering all aspects of the service. It was identified the majority of action was to be completed by October / November 2025. We found areas for improvement remained outstanding and actions had not been taken in a timely way.

Feedback received people’s relatives also reflected their concerns about the lack of progress. We were told, “So many different people/staff, changes all the time. No manager. No activities. The only thing that changed since the last time the CQC came was they got the decorators in, nothing else” and “They have a lot to sort out. Falls are not witnessed which means staff are not around, they are very low on staff and there are no activities.”

The provider had a comprehensive quality assurance policy, setting out what systems they would use to monitor, audit and analyse the quality of the service provided. A review of records showed some of the methods were not in place. This included; Quality Circles, Co-production (giving power to residents), value-based recruitment, monitoring and observation of staff and regular in-house audits.

Records showed recent in-house audits had been introduced. However not all areas had been completed. Checks had also been undertaken by the newly appointed deputy manager, who had not undertaken additional training relevant to their new role and responsibilities. Improvements were also needed to records held within the home including care records and health and safety checks.

Information showed monthly clinical reports were completed by the senior management team. Newsletters were provided outlining best practice guidance and information for staff. We were told staff now signed to say information had been read. However, there was no evidence to show how any learning had been put into practice, improving outcomes for people. A quarterly residential home audit was also undertaken. This was last completed October / November 2025. A number of areas for improvement were identified, which were to be reviewed in December 2025. There was no information to show this had been done.

As already stated the local authority quality monitoring team had issued the provider with an action plan following their quality review. Regular monitoring visits were being undertaken to monitor and review the service.

We found notifications which should be submitted to CQC by law, had not always been provided. Again, it was felt this was due to the lack of effective management oversight.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff worked with health care professionals who were involved in people's care and treatment. Details of appointments and any action required was recorded in people’s care files.

Following our site visits, we were told the new manager was exploring community groups and organisation to support social inclusion through visits and activities. It was anticipated this work would be explored further by the newly appointed activity staff.

The service continues to work with the local authority. Regular monitoring visits had been made to review the action plan in place to address areas of contract compliance.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Following our last inspection the provider had developed a ‘service improvement plan’ detailing the areas of improvement and action required. Timescales for completion were also noted. However, on review a number of areas remained outstanding, such as such as staff induction training, improved care planning and involvement and refurbishment of the home taking into consideration people’s views and sensory needs. A further action plan had been introduced by the local authority following their quality review.

As detailed within the report, more robust systems were needed to help identify and act on areas for improvement or concerns, such as in-house audits and checks and reviews of accidents and incidents, so themes are quickly identified and acted upon and any learning is also shared with staff.

Other opportunities to support staff learning also needed embedding, such as supervision and development in line with the providers policy.