Bridge Haven

Bridge Haven is a residential care home providing accommodation and personal care to up to 53 people, some of whom live with dementia. At the time of the inspection there were 40 people living at the service.

People’s experience of using this service and what we found

People told us they were happy living at Bridge Haven. There was a calm and relaxed atmosphere and people and staff had forged positive relationships.

Staff were not consistently recruited safely by the provider. This was an area for improvement. There were enough staff, who knew people well, and met their needs in the way they preferred.

People were protected from the risks of abuse and discrimination by staff who were trained to recognise signs of abuse and discrimination. Staff understood their responsibilities in relation to keeping people safe and knew how to report any concerns. The registered manager liaised with the local authority safeguarding team when they had any concerns to make sure the correct action had been taken.

Staff wore personal protective equipment (PPE) and followed guidance to make sure this was disposed of safely. Staff had access to PPE whenever they needed it. The service was clean, and all areas of the service were regularly cleaned.

The registered manager completed regular audits to monitor the quality and safety of the service. Additional checks were conducted by external contractors and a plan was in place to monitor the actions being taken when shortfalls had been identified.

The registered manager was aware of their regulatory responsibilities and notified the Care Quality Commission (CQC) in line with guidance.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 31 July 2018).

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels and the management of a Covid outbreak within the staff team. The inspection examined those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Bridge Haven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Bridge Haven accommodates up to 53 people in one purpose built building. There were 36 people using the service during our inspection.

There was no registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had been appointed in December 2017, they had applied to CQC to become registered as the manager at the time of this inspection, but no decision had yet been made about their application. In the week following this inspection a decision was made to agree their application.

Bridge Haven was last inspected in April 2017. One breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified. We issued a requirement notice relating to safe care and treatment. We asked the provider to take action and they sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found improvements had been made, and the previous breach had been met.

At our previous inspection medicines were not consistently managed safely. At this inspection we found that improvements had been made and medicines were now managed safely. At our last inspection we recommended that the provider ensured sufficient staff were on duty to meet people's needs. At this inspection we found that staffing levels were safe and met people’s needs. People told us they felt there were enough staff and they didn’t have to wait long when they needed help. The manager had focused on ensuring there were enough staff by focusing on recruitment, looking at different ways of recruiting staff, such as open days.

People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. Staff knew about the whistle blowing policy and were confident they could raise any concerns with the provider or outside agencies if needed.

Equipment and the premises received regular checks and servicing to ensure it was safe. The manager monitored incidents and accidents to make sure the care provided was safe. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. The premises were designed, adapted and decorated to meet people’s needs and wishes. The manager told us about plans to further improve the environment for people; these included improving some outside areas and some of the communal areas.

Staff had completed induction training when they first started to work at the service. Staff were supported during their induction, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people's needs. There were staff meetings, so staff could discuss any issues and share new ideas with their colleagues, to improve people's care and lives.

Staff worked well together and ensured that clear communication between themselves and external health professionals took place; for example, with care managers, commissioners, GP's and district nurses.

The care and support needs of each person were different, and each person's care plan was personal to them. People had detailed care plans, risk assessments and guidance in place to help staff to support them in an individual way. Some plans did not contain clear and specific guidance for staff, however, after we highlighted this to the manager they took steps to ensure this was immediately put right.

Staff encouraged people to be involved and feel included in their environment. People were offered varied activities and participated in social activities. Staff knew people and their support needs well. Staff were caring, kind and respected people's privacy and dignity. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. Staff had an understanding of The Mental Capacity Act (2005) and when people lacked the capacity to consent to staying at the service, the registered manager had applied for Deprivation of Liberty Safeguards (DoLS.) People were involved in making decisions about their care and staff knew how to communicate with them.

People were encouraged to eat and drink enough and were offered choices around their meals and hydration needs. Staff understood people's likes and dislikes and dietary requirements and promoted people to eat a healthy diet. The service was not currently supporting anyone at the end of their life.

Quality assurance audits were carried out to identify any shortfalls within the service and how the service could improve. Action was taken to implement improvements. Staff told us that the service was well led and that they felt supported by the manager to make sure they could support and care for people safely and effectively. Staff said they could go to the manager at any time and they would be listened to.

The registered manager was fully aware of their regulatory responsibilities and had notified us of any important events that had happened in the service. The rating was displayed clearly on a notice board in the hallway and on the providers website. The manager had fostered links with the local community and encouraged staff involvement in developing the service. A system to respond to concerns was in place. People and their relatives knew how to raise concerns and were confident they would be listened to.

The service provides accommodation and personal care for up to 53 older people with dementia; there were 37 people in residence at the time of the inspection. The accommodation is provided on one level and this is divided into two units 'Primrose' and 'Bluebell'. One unit accommodates 29 people and one unit accommodates 24 peoples. Separate dining and lounge areas are provided in each unit but these are visible from each unit and people can move freely between these areas.

At our previous inspection of this service in September 2016 we issued an enforcement notice for Regulation 17 in respect of quality monitoring and quality audits; these were shown to be ineffective in identifying and addressing recurrent and new breaches of regulation. We required the service to be compliant with the enforcement notice by the end of December 2016. We also issued requirement notices in respect of regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 16 Receiving and acting on complaints and Regulation 18 Staffing. We asked the provider to send us an action plan of what improvements they intended to make to address these shortfalls. An action plan was sent to us when requested. Since the last inspection we received information of concern about staffing levels and some care practice issues at the service

Since the previous inspection the service had seen a change in its management team. A new manager and deputy manager were now in post. The new manager had applied to register with the Care Quality Commission and their application was in progress. A registered manager is a person who is 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.

This inspection highlighted that overall progress towards meeting the regulations had improved but further improvements were needed. The provider had taken all reasonable steps to address the staffing issues, however, there was a need for staffing to stabilise and improvements to be embedded and sustained over a longer period of time. We have made a recommendation about this.

People and their relatives were involved in the development and review of care and support plans including end of life wishes, this informed and guided staff about people’s needs and preferences. Relatives felt confident raising concerns and complaints were appropriately managed. People were able to make decisions and choices for themselves about how they spent their time, but there was no mechanism for recording their level of participation. People’s behaviour was monitored using an appropriate tool. However staff needed guidance on how to monitor this effectively to help inform the support they provided to people.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff sought people's consent on a daily basis. However, improvements were needed in how staff recorded people capacity to make decisions. We have made a recommendation about this.

During inspection the atmosphere in the service was calm and the majority of people were in positive moods; those who were not were appropriately supported by staff. People lived in a well maintained clean environment where equipment for their use and safety was serviced and checked regularly. Care and domestic staff said they felt happier with the new management team and morale was improving. Relatives spoke positively about the care being delivered, the attitudes of staff and confidence in the new management team. They voiced concerns about the level of staff turnover, staff shortages and the use of agency and the impact this had on continuity of care for people, but felt things overall were improving.

Health professionals were positive about the general wellbeing of people. However, they felt the partnership working could be improved.

Recruitment checks of staff had been strengthened and improved to ensure new employees were suitable to work with vulnerable people. Staff showed they knew how to keep people safe from harm and abuse and risks were appropriately assessed. Staff received appropriate induction and training for their role and their performance, development and training was assessed through regular supervision and annual appraisal. Staff said they felt better supported and listened to by the new management team.

Staff treated people well and spoke kindly to them treating them with respect, ensuring their dignity was maintained. People were encouraged to retain as much independence as they were able to. New people into the service were assessed before admission to ensure their needs could be met. People were able to bring personal possessions to make their rooms more homelike and help them settle in. They were supported to maintain links with the important people in their lives. Visiting times were flexible and visitors were made welcome.

Relatives were provided with opportunities to express their views through family forum meetings.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The service provides accommodation and personal care for up to 53 older people with dementia; there were 42 people in residence at the time of the inspection. The accommodation is provided on one level and this is divided into two units ‘Primrose’ and ‘Bluebell’. One unit accommodates 29 people and one unit accommodates 24 peoples. Separate dining and lounge areas are provided in each unit but these are visible from each unit and people can move freely between these areas.

At our previous inspection of this service in July 2015 we found the service was not meeting the required standards in respect of staffing levels and staff training knowledge and skills. We took enforcement action to require the provider to address these shortfalls quickly, there were also additional breaches in a number of regulations and we asked the provider to tell us how they were going to address these. This inspection was to assess whether the improvements they had told us about had been embedded and were now everyday practice.

We had been informed that the registered manager had recently left. Interim management was being undertaken by the two deputy managers with support from senior staff in the organisation. A registered manager is a person who is 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.

People and relatives told us that they were satisfied with the quality and delivery of care provided in the service. Relatives did however, express concerns about recent turnover in staff, the need for agency staff to fill gaps in the rota and the impact this had on continuity of support for their own relatives. Professionals raised no particular concerns in regard to care delivery but some recognised the service needed support in some areas to up skill their staff and were now working with the service staff to improve awareness and provide training in areas such as skin integrity and end of life care.

Our inspection highlighted that whilst the provider had taken action to improve recruitment in the service this was not enough to ensure people received continuity of support from staff that understood their needs well and did not therefore meet previous enforcement action we had taken. Progress overall towards meeting previous shortfalls was disappointing with some continued breaches. We found that there was still a need to stabilise staffing and ensure the present dependency tool was suitable for the needs of the people supported. CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff sought people’s consent on a daily basis. A DoLS application had been authorised for a number of to ensure that they were not deprived of their liberty unnecessarily, however evidence of evidence of assessment of peoples capacity to make decisions was lacking within care records seen.

Risks were not always identified or measures implemented to reduce harm. Gaps in information held about people’s health conditions could place them at risk of receiving inappropriate support. The absence of a hand wash sink in the laundry could compromise staff maintaining good infection control standards. Recording around the action taken to address people’s minor concerns was lacking and did not meet the company policy requirements to show people were being listened to however minor their concerns. Most significantly the quality audit and monitoring processes established by the provider had failed to identify that the service was failing to deliver on its previous action plan to address shortfalls, or to monitor the manager’s operational management performance or concerns within the staff team.

We acknowledge that there has been some progress but there remain other areas for further improvement that include the need to ensure in the event of fire care staff can keep people safe by receiving regular fire drill training; that evacuation plans for individuals are expanded to make clear what methods staff will use to evacuate people without reliance/or expectation this will be done for them by the fire service. This would be in accordance with provider responsibilities under the Fire safety Order (2005) Reform. The provision of activities is also an area for further improvement as this is often dependent on the availability of staff which in view of the present unsettled staffing means activities are not routinely happening on days when staff are expected to facilitate these.

In all other respects we found that the premises was kept clean and well maintained providing a pleasant environment for people to live in. Important servicing and checks were undertaken to ensure gas and electrical installations, the fire alarm and other equipment used in the support of peoples care was in safe working order .Medicines were managed appropriately. Staff recruitment procedures ensured important checks were made of staff suitability. New staff received appropriate induction and were provided with a programme of training to fulfil their role. Staff said they felt better supported and listened, although frequency of formal supervisions had drifted; staff felt able to seek out senior staff in the service at any time if they needed to talk or raise issues.

People’s health needs were assessed and monitored. A health care professional said that the staff were good at seeking professional advice when it was needed. People were provided with a varied diet that reflected their personal likes and dislikes, and dietary needs.

Staff treated people well they spoke kindly to them and treated them with respect, ensuring their dignity was maintained. People were able to bring personal possessions to make their rooms more homelike and help them settle in .They were able to make decisions and choices for themselves about how they spent their time, who with and where. Care plans guided staff in how people wanted to be supported in accordance with their needs and wishes. Staff took their lead from people in how much support they needed and wanted respecting their right to continue to attend to some aspects of their own care for themselves.

The atmosphere in the home was welcoming, visiting times were flexible and visitors were made welcome. People and their relatives were consulted about their care and end of life wishes and were provided with opportunities to comment about the service. People were supported to maintain links with the important people in their lives.

We have made two recommendations:

We recommend that the provider arranges for a competent person to assess the safety of all portable electrical appliances used by residents at least annually.

We recommend that the provider seeks advice from a reliable source to ensure that the personal evacuation plans in place and the frequency and recording of fire drills for care staff meet the requirements of current fire legislation.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Bridge Haven can provide accommodation for up to 53 older people, who may have dementia. There were 43 people using the service at the time of our inspection.

We considered our inspection findings to answer 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. This summary is based on our observations during the inspection, discussions with people using the service, staff supporting people and the management team and the records we looked at.

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

Is the service safe?

Staff were able to identify when people may be at risk of abuse and knew how to raise their concerns inside and outside of the service.

There were systems in place to make sure that the staff learned from accidents and incidents.

Care was planned to ensure that people received safe and appropriate care. Care plans detailed each person's individual needs. When risks to a person were identified the service took action to manage the risk to them. However, more information and detail was required in some care plan records to support staff to provide safe and consistent care.

Is the service effective?

Staff knew people well, they responded to people's requests and offered them choices. Staff knew what people were able to do for themselves and supported them to remain independent.

The provider operated an effective system to regularly assess and monitor the quality of the service provided. There were systems in place to ask people using the service, their relatives and staff for their views about the service and they were acted on.

Is the service caring?

People were supported by kind and attentive staff. Staff showed patience and gave encouragement when supporting people. People we spoke with said they liked the staff. Staff engaged with people positively when supporting them throughout our inspection.

The service worked closely with health and social care professionals to maintain and improve people's health and well-being.

Is the service responsive?

It was clear from observations and from speaking with staff that they had a good understanding of the people's care and support needs. Staff sought extra help and advice from other health and social care professionals when required.

Staff were attentive to people using the service and responded promptly when needed.

The management team ensured that adequate numbers of staff were on duty to meet people's needs at all times.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities and that they felt supported by the new management team.

Staff rotas were planned to balance the number of agency staff and substantive staff, to ensure that staff who knew people well were always available to support them.

There was an effective system to regularly assess and monitor the quality of the service to protect people's health, safety and welfare.

We found that when people who used the service had fallen, care plans and risk assessments were not always updated. The service did not monitor falls to identify trends or patterns.

Staff told us how they supported people who present as aggressive or anxious. However, there was no information in the care plans to provide staff with guidance.

We found that the service had taken appropriate action to obtain health care support for people when their needs changed and that referrals were made to the dietician and district nurses. However, we found that the care prescribed was not always followed.

The registered manager told us that they had recently recruited several new staff members and all vacancies were now filled. However, we found that there was not always enough qualified, skilled and experienced staff on duty to meet people's needs.

We found that the service did not have effective processes in place to assess and monitor the quality of the service the people received.

There were systems in place to ensure that there was communication between staff members, between shifts, relatives and professionals. We found that the provider had an effective system in place to receive, record, investigate and resolve complaints.

We also looked into how the service communicated between staff, with relatives and with health professionals, how often and how effectively care plans and risk assessments were evaluated and reviewed, how the service managed and responded to complaints and we checked staffing levels to make sure that there were enough staff to meet people's needs.

We found that assessments were carried out and care plans and risk assessments were reviewed and updated. Advice had been sought from health professionals including doctors and district nurses, especially when a person became unwell or their needs changed. This had led to the provision of aids, adaptations and equipment so that people were more comfortable.

Care plans and other records showed that relatives and loved ones had been involved in assessments and care plan reviews. Some people or their relatives had completed a book entitled 'About me' giving written information about the person and their life history.

There were systems in place to ensure that there was communication between staff members, between shifts and between staff, relatives and professionals. We found that complaints had been recorded and responded to with procedures in place to try to resolve complaints.

We found that the high use of temporary or agency staff led to an inconsistency in care. One person said 'They (agency staff) don't know me. They don't know how I want to be cared for. It's alright for me; I can speak for myself and tell them. But some people can't.' We found that recruitment to vacant care staff posts was underway and the manager said they hoped to get the vacancies filled soon. We will follow this up at the next inspection.

People told us that the staff were kind and that there were enough staff to meet their needs. Staff spoke with people in a calm, positive reassuring manner. We saw a staff member hold a person's hand to comfort them when they became upset and asked them if they were alright. The person smiled positively in response to this support. One person said 'The staff could not be better.'

People maintained good health and mental health as the service worked closely with health and social care professionals. Activities were provided which were advertised and people had support to take part in meaningful activities and tasks.

People were treated with respect and their dignity and privacy maintained. People said they felt safe and had the care and support they needed. A visiting relative told us that they felt their relative was safe and had the care and support they needed. They said they were kept informed about their relative's well-being and were always made to feel welcome when they visited the home.