This inspection took place on 26 June and 4 July 2018 and was announced. We gave 24 hours’ notice of the inspection visit because the service is small and people are often out during the day. We needed to be sure they would be in.

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. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides personal care to a maximum of seven people who have a learning disability. At the time of the inspection there were six people who used the service.

At the last comprehensive inspection in November 2015 we found the service was meeting requirements and was awarded a rating of Good. At this inspection we found the service had deteriorated and we rated the service as Requires Improvement.

The service had a newly registered manager. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The inspection highlighted that at times there were insufficient staff deployed to meet the needs of people who used the service and to ensure they all engaged in meaningful activity.

On the first day of our inspection we found cleanliness to be poor, particularly in bathrooms and shower rooms. We also found the stairway to be dusty, dirty and in need of cleaning.

We found parts of the home were not safe. We found loose blind cords and a bedroom window restrictor which was easily overridable. We informed the registered manager about the poor cleanliness and safety concerns who told us they would take immediate action to rectify these. When we returned for our second day of the inspection we found that action had been taken to address the issues around cleanliness and safety.

The provider had identified that people’s needs were changing and the premises were no longer suitable for its intended purpose. People’s mobility had deteriorated and some were having difficulty with using the stairs. They were in the process of looking for a bungalow for people. However, in the interim some areas of the service and furniture had got into a poor state of repair. The service did not have a window cleaner and all windows were very dirty. Walls were scuffed and paintwork chipped. The service needed redecoration. Externally plants and shrubs had become overgrown and were covering windows.

We found some furniture and soft furnishings to be worn and in need of repair or replacement Externally, there was seating in the form of a table and bench, however this was unsuitable for people who used the service. We pointed out our findings to the registered manager.

When we returned for our second inspection visit we found that furniture had been repaired and where needed replaced. The windows had been cleaned and a window cleaner was to visit once a month to keep on top of these. After the inspection we were informed that new garden furniture had been delivered.

The inspection of this service identified that some audits undertaken by the registered manager and provider were ineffective as they did not pick up on the areas we identified as needing improvement.

During this inspection we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Relatives told us people were safe at Bridge House. Staff under

We visited Bridge House on 19 and 27 November 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

At the last inspection in January 2015 we found the registered provider was breaching three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These related to assessing and monitoring the performance of the home; consent and the management of medication. We also found they were breaching their condition of registration, as there was no registered manager in post.

Following the inspection the registered provider supplied a comprehensive action plan that detailed how they would ensure compliance with the regulations. We found at this inspection that the registered provider had taken action to address the concerns. We found that the operational manager and registered manager had made significant improvements to the operation of the home.

Bridge House is a two-floor detached house set in its own grounds. A second separate small care home was built in the grounds and this service operates independently from Bridge House. The home accommodates up to seven people with learning disabilities.

The manager came into post in March 2015 and became the registered manager in June 2015. 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.

We heard about a range of improvements the staff had made to the way the service was operated. The operational manager, registered manager and staff told us that this year they had been finalists in the Great British Care Awards and won a Silverline Dignity in Care Award. We found that all of staff acknowledged that because of a lack of training, coaching and mentoring they had previously adopted institutionalised practices. The operational manager and registered manager clearly outlined the areas of work the organisation had identified as needing improvement and the steps they and staff had taken to make positive changes to the way they worked with people.

The operational manager and registered manager told us that every single member of the team had fantastic values and attitudes towards supporting adults with a learning disability and wanted to learn, improve and achieve positive outcomes for the people they supported, who they cared very much about. They added that the problems that had been faced in the home were not with the team themselves, but with the way they had been led.

At the time of the inspection six people lived at the home and we met five of the people who used the service. They were unable to verbally communicate what they thought about the home and staff. Therefore we spent time observing how the staff interacted with people and work with each individual. Staff could clearly outline each person’s needs and associated risks, such as what they needed to do if a particular person became distressed, how to deescalate behaviours that challenge and what support people needed when outside.

We found that the since the registered manager had come into post significant changes to practice had occurred and now staff consistently ensured people were going out into the community. Staff had been supported to identify triggers for people that would lead them to become distressed. We found this had a very positive impact on people’s level of distress and the number of occasions when people displayed behaviours that challenge had markedly reduced.

Staff were aware of how to respect people’s privacy and dignity. We saw that staff supported people to make choices and decisions.

We saw that detailed assessments were completed, which identified people’s health and support needs as well as any risks to people who used the s

At our last inspection in August 2013 we found that people were not always protected from the risk of infection. We wrote to the provider and asked them to make improvements. The provider wrote to us and told us that they had taken action to address the concerns.

At this inspection we reviewed the actions the provider had implemented. We spoke with the registered manager and two members of staff and discussed the actions implemented by the home.

We looked around the home and saw that concerns we raised about the cleanliness and risk of infection had been addressed. The manager told us they are continually reviewing the plan and continue to update the environment.

The manager showed us a recent audit that had been completed which looked at service provision in the home including cleanliness and infection control showing positive results.

During the inspection we observed the experiences of people who lived at Bridge House. We saw that staff communicated and interacted well with people in a way they could understand. We saw that the atmosphere was friendly and relaxed. The staff were attentive and demonstrated a good knowledge and understanding of people’s needs.

We saw that people had their needs assessed and that care plans were in place. We saw that there were effective processes in place to ensure safe sharing of information with other providers.

We found that people were not always protected from the risk of infection.

We found that the service had effective recruitment procedures in place.

We found that systems were in place to monitor compliments and complaints.

We observed one person living at the home taking staff by the hand and leading them to the kitchen where they were then supported to make a cup of coffee.

We spoke with another person who said they liked living at the home. They told us that they went to the shops, the cinema and pubs and were able to go and visit their family.

The person we spoke with said they felt safe and liked living at the home. We were told that they liked the staff who worked at Bridge House.

We observed positive interactions between those living and working at the home.

People using the service were unable to communicate verbally with us, because of their complex needs, so we spent time observing the care that people received to determine their experiences of care. We observed staff supporting people in a way that maintained dignity and respect. We also observed them taking into account people's behaviour and body language to support people to make decisions for them selves.

From observing people at Bridge House and talking to their staff, it was clear that at times people did not get on with one another. The staff told us that prior to moving into Bridge House two people were known not to get along. This was not considered at the time of placement into the home, and so they continue to be antagonistic at times.

In Bridge House there was evidence that staff really cared about the people using the services and clearly understood peoples' needs. Staff had developed a good relationship with people and were aware of how to support people to manage their behaviour. Through out our visit staff were seen to interact regularly with individuals, by talking and singing to people, to encourage interaction and involvement.

We visited Bridge House on 9, 22 December 2014 and on 14 January 2015 we met one of the registered managers who was providing registered managerial oversight. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

Bridge House is a two-floor detached house set in its own grounds. A second separate small care home was built in the grounds and this service operates independently from Bridge House. The home accommodates up to seven people with learning disabilities.

In November 2014 concerns were raised around the general operation of the home and that staff were not supported to adopt best practice guidelines when supporting people. This meant that staff were not adopting positive risk-taking measures or supporting people to be as independent as possible. We found that the provider had started to take action to ensure the staff understood how to provide care and support that encouraged people to develop their skills but this was at a very early stage of implementation.

The home does not have a manager in post. The previous registered manager left in July 2014 and cancelled their registration on 30 October 2014. 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.

We found that there was a lack of managerial oversight of the home. Since the previous registered manager left three managers from other homes and the operational manager had been overseeing the service. On each occasion that we visited no manager was on site. We found the registered manager from the adjacent home had provided support but was no longer doing so and one of the managers from a different home now went to the home, when possible, around two days a week. This manager had completed some work with staff to improve the service as had the operational manager. However, we found the lack of stable management oversight meant staff were not adequately supported to make changes.

When we completed visits the senior carers were out with some of the people who used the service as they were the only ones with a driving licence. The remaining staff could not access the registered managerial records; could not administer medication and where unclear as to who was providing overall management. On each subsequent visit we found that there was no registered manager on site and staff did not know when the registered managers covering the home would visit.

We found that one of the managers providing oversight could remotely provide us access to training and supervision records but staff at the home did not know how to do this. Also they could not provide us with any accident and incident analysis, complaints records, quality assurance records, medication audits, maintenance records, surveys, staff and resident meeting minutes or records in relation to behavioural incidents and care record audits. On three occasions we asked for this information to be provided but this was not supplied.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards training but were unclear about the requirements of the Act. No records were in place to show that staff completed capacity assessments where appropriate and made ‘best interest’ decisions. We found that all of the people were under constant supervision and prevented from going anywhere on their own. This included leaving the building to go into the garden or over to visit people at the other home, although both properties were enclosed by a six foot fence. Staff did not know whether people were subject to DoLS authorisations, which are needed if people lack capacity to make decisions and these types of restrictions are made. Staff could not tell us if any DoLS had been applied for or who was responsible for making these applications.

People living at the home required staff to provide support to manage all of their day-to-day care needs as well as to manage their behaviour and reactions to their emotional experiences. We found that the staff were very caring and understood each person’s needs but the records did not reflect the work they completed or reflect people’s current needs. We found that the provider had identified this gap and one of the managers who provided oversight had reviewed the care records to determine what action needed to be taken.

We saw that people had plenty to eat. We saw that each individual’s preference was catered for and staff ensured that each individual’s nutritional needs were met. Staff monitored each person’s weight and took appropriate action if concerns arose. However, the records did not accurately show the actions staff were taking to ensure people received a healthy diet.

People had complex needs and very limited verbal communication. We found that the provider had assessed the dependency needs at the home and one person had recently been provided with one-to-one care. We saw that four staff were on duty during the day and two staff members were on duty at night. Staff told us this staffing level had been the same prior to the introduction of the one-to-one. The operational manager explained that the staffing levels had been increased whilst agreements for one-to-one were obtained and these were the correct levels for the people who used the service. From discussions with staff we found that the staffing levels provided sufficient cover.

We found that the care staff were responsible for cleaning the house and although aware of the infection control procedures and environments no process was in place to complete deep cleans. Some of the people had continence management needs and this meant these deep cleans were needed on a regular basis.

We found that senior care staff completed safe handling of medication training and were the only people who could administer medicines. However, if they were the only designated driver on duty they needed to leave the home, which meant no medicines could be administered when they were out. The remaining staff did not have access to the medicines and were unable to show us how these were stored.

Staff had received a range of training, which covered mandatory courses such as fire safety as well as condition specific training such as managing epilepsy and other physical health needs. We found that the staff had the skills and knowledge to provide support to the people who lived at the home. We saw that the system allowed for the registered managers to remotely oversee staff progress in completing mandatory training and remind staff that this needed to be completed. One of the registered managers overseeing the service found that staff had not completed supervision since September 2014 or their yearly appraisals so was taking action to ensure these were completed.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

We saw that people living at Bridge House were supported to maintain good health and had access a range healthcare professionals and services. We found that staff worked well with people’s healthcare professionals such as GPs and community nurses.

We saw that the provider had a system in place for dealing with people’s concerns and complaints. People we spoke with told us that they knew how to complain and but did not have any concerns about the service.

We found the provider was breaching a number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These related to use of registered managerial oversight, records keeping, assessing and monitoring the performance of the home; consent and the management of medication. You can see what action we took at the back of the full version of this report.