The inspection took place on 7 and 8 June 2017 and was unannounced on the first day and announced on the second.

Bridge House Nursing Home is a care home with nursing. It is comprised of two units, one known as Bridge House and the other as Bridge Court. It is registered to accommodate 54 people across both units. At the time of the inspection 20 people were resident in Bridge House and 13 in Bridge Court. Some of the people living at the service may require either nursing or specialist care associated with dementia and other conditions.

At our last inspection in November 2016 the provider was not meeting four Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the service was rated requires improvement. Requirement notices were issued with respect to the breaches of Regulation 12 (safe care and treatment), Regulation 9 (Person centred care), 17 (Good governance) and 19 (Fit and proper persons employed).

The provider sent us an action plan in January 2017 outlining the improvements they were going to make in order to meet the requirements of the regulations.

This inspection was a comprehensive inspection to follow up and ensure the requirements of the previously identified breaches of regulations had been met and to make a judgement about the overall compliance of the service. At this inspection we found significant improvements had been made and there were plans in place to maintain and further improve the quality of the service. The requirements of the regulations had been met.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At the time of the inspection there was no registered manager. Two managers had been appointed since the previous registered manager deregistered. Both had submitted applications to become registered with the care quality commission to manage the service however, both left the service prior to the registration process being completed. Following discussions with the provider the operations manager who had worked with and supported the service for a significant amount of time had begun the process to become the registered manager.

People were safe and told us they felt so. Risk assessments had been completed and plans were in place to manage and limit any identified risks. Incidents and accidents were reviewed, investigated and monitored to identify emerging trends and enable action to be taken to reduce their occurrence. Recruitment procedures were thorough and established so far as possible the suitability of staff to work with people. There were sufficient numbers of staff to care and support people safely. Staffing levels were calculated according to the needs of people using the service and were reviewed regularly. People were protected from abuse by staff who had been trained in safeguarding people and understood how to report concerns. Medicines were ordered, stored and administered safely. The provider had a business continuity plan which provided guidance for staff on the actions to take in a foreseeable emergency.

People were supported by staff who had received training to perform their role effectively. Induction was provided to new staff who also shadowed experienced staff until they were confident and competent to work unsupervised. Staff were supported by the manager and other senior staff who we were told listened and took action when necessary. Further support was provided through one to one meetings, staff meetings and annual appraisals. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems

The inspection took place on 25, 28 and 29 November 2016 and was unannounced.

Bridge House Nursing Home is a care home with nursing. It has recently been extended to create an additional unit and is now registered to accommodate 54 people. At the time of the inspection 35 people we resident and receiving care. Some of the people living at the service may require either nursing or specialist care associated with dementia.

At our last inspection in June 2015 the provider was meeting the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the service was rated good overall. However, the Care Quality Commission received concerns regarding the service from the local authority which prompted this inspection.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. At the time of the inspection there was no registered manager. A manager had been appointed and had begun the process of applying to CQC to become the registered manager. However, since the inspection the provider has informed us this manager has resigned. Satisfactory, interim arrangements have been made to manage the service until a new manager is appointed.

Risk assessments did not always have sufficient information or detail to mitigate identified risks. Duplication of documents in relation to managing risks had the potential to confuse staff and increase the risk for people. The service was addressing this by reviewing all care plans and risk assessments to provide clarity.

People at risk of developing pressure sores were not always protected from this risk. People’s pressure mattresses were not always set to the correct pressure.

Care plans did not contain sufficient detail of people’s preferred routines to enable staff to provide personalised care to people.

Records were difficult to read and sometimes illegible. They were not always completed promptly after delivery of care, leaving a potential for them to be inaccurate.

Recruitment procedures were not followed robustly to ensure appropriate people were employed at the service.

The provider had systems in place to monitor the effectiveness of the service. However, these did not always identify all concerns. Where they did identify concerns the resulting action plans had not been completed to improve the service.

Notifications required by law were not always submitted to the CQC.

People’s needs were attended to promptly and there was a staff presence in all areas of the service during the inspection. However, we were told that at times staff felt rushed and stretched. We found a dependency tool used to calculate staffing levels was not always completed accurately.

Staff did not feel fully supported by all members of the management team. Staff support mechanisms were in place. However, until recently one to one supervision meetings had not been held for all staff, although group meetings had been provided as support. The manager had planned dates for all staff to have a one to one meeting on a regular basis going forward. Further support was available in the form of staff and team meetings and annual appraisals.

Training was provided for staff but we found staff had not always refreshed their training in accordance with the provider’s policy.

People told us they felt safe and staff had a clear understanding of how to safeguard people and protect their well-being. They were aware of how to report concerns.

Medicines were managed and administered safely. The storage areas for medicines were found to be warmer than the optimum temperature recommended. This was addressed after it was raised during the inspection.

Applications fo

At an inspection on 22 July 2013 we found the provider had not ensured there were suitable arrangements in place for obtaining, and acting in accordance with, the consent of people who use the service. Where people may have lacked capacity to consent to their care, suitable arrangements were not in place to establish and act in accordance with the best interests of the people in the home.

At this inspection we found the provider had taken some positive actions to demonstrate that lawful consent to care and treatment was obtained from the appropriate person. Training had improved staff awareness of mental capacity assessments, when it was appropriate to consider best interest decision-making, and who could lawfully consent to a person’s care and treatment on their behalf. Meetings had been arranged for relatives to explain the scope of holding a Lasting Power of Attorney, and when this could lawfully be used to provide consent on behalf of others.

However, we found records did not always demonstrate evidence of mental capacity assessments, which would indicate when best interest decision-making would be appropriate. We saw records indicated relatives consented to care or treatment on people’s behalf without evidence of a lawful right to do so. This meant the provider had not established suitable arrangements to lawfully obtain, and act in accordance with, the consent of people who use the service.

At our inspection on 22 July 2013 we found the provider did not have sufficient qualified, experienced and skilled staff to meet the needs of people who use the service at all times. At this inspection we found staffing was sufficient to meet the needs of people throughout the day and night. Staff told us staffing levels had improved. We observed meal times had been staggered to ensure sufficient staffing was available to support people to eat their lunch. Staff rotas demonstrated the manager considered people’s dependency and support needs when deciding staff cover for shifts.

On the day of our inspection there were 24 people living at the home plus three people staying on a short term, respite care basis.

Since our last inspection the provider had employed a new manager for the home, who took up her position at the beginning of April 2013. The new manager is aware of the steps needed to become registered as the manager for Bridge House Nursing Home.

People were protected from the risks of inadequate nutrition and dehydration. The manager was aware of the NHS England heat wave guidelines and had implemented government guidelines to protect people from heat wave related risks.

The provider had introduced changes aimed at ensuring sufficient staff were on duty at all times to meet the needs of people living at the home. Other steps were underway to ensure further improvements could be implemented and maintained. However, the provider had not fully ensured there were enough qualified, skilled and experienced staff, at all times, to meet people’s needs.

People told us staff took time to explain what was happening before doing things. One person commented "They ask me before doing anything." Another person commented "They tell me what is happening." During our visit we saw, before they received any care, people were asked their consent and staff acted in accordance with their wishes. However, in relation to care and treatment, the provider did not have suitable arrangements in place for obtaining the consent of people living at the home.

Care plans and other records related to the management of the service were up to date and accurate. They were kept securely and could be located promptly when needed.

People told us staff treated them with respect and supported them to make their own choices. One person said “I can get up in the morning when I want to.” Another person told us that staff respected their preference to their meals in their bedroom. Care was planned with the involvement of the people who live in the home and their relatives, and reflected people's individual needs. People told us they trusted the staff and felt safe in their care.

There were arrangements in place to support workers. Staff received appropriate training and supervision. However there were not always sufficient numbers of appropriate staff to ensure that the health and welfare needs of people living in the home were met at all times. There were processes in place for recording, investigating and resolving complaints from people who use the service and their relatives. The people we spoke with were aware of who they would speak to if they had any complaints.

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 of this inspection. We have advised the provider of what they need to do to remove the individual's name from our register. We have advised the provider of the requirement to register a new manager in respect of all regulated activities offered by this service.

Residents who could express a view told us they were very happy at the home. They said that the staff were “caring” and “helpful

They told us "the food was good and they looked forward to meal times".

Relatives told us that "the home was lovely, the staff were good, and that issues were dealt with promptly". They told us that "they believed their relatives were safe living at Bridge House Nursing Home".

The inspection took place on 5 and 8 June 2015 and was unannounced.

Bridge House Nursing Home is a care home with nursing. Although registered to provide a service for up to 47 people, the service currently has accommodation for 32 people. This is because previously shared occupancy rooms are now only used for single occupancy. Some of the people living at the service may require either nursing or specialist care associated with dementia.

At our last inspection in April 2014 we identified a breach Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to the arrangements in place for obtaining the consent of people who lack capacity. Following that inspection the provider sent us an action plan telling us the improvements they were going to make. At this inspection we found that improvements had been made.

The home is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. At the time of the inspection there was no registered manager. However, arrangements for day to day management of the service had been provided by interim managers and the matron. A new manager had been appointed and was due to commence working at the service on 1 July 2015. They had submitted relevant applications to the Care Quality Commission (CQC) to become registered.

Staff were aware of how to keep people safe by reporting concerns promptly through procedures they understood well. Systems and processes were in place to recruit staff who were suitable to work in the service and to protect people against the risk of abuse. There were sufficient numbers of suitably trained and experienced staff to ensure people’s needs were met.

People using the service told us they were happy. Relatives also said they were very happy with the support and care provided at the service. People and when appropriate their relatives confirmed they were fully involved in the planning and review of their care. Care plans focussed on the individual and recorded their personal preferences. They reflected people’s needs. However we found one example where a person did not have a care plan. After speaking with the interim manager and matron we were assured this was an isolated incident due to the person being recently admitted to the service. By the second day of the inspection this had been addressed and the care plan had been written and reflected the needs of the person.

People told us communication with the service was good and they felt listened to. People and their relatives told us staff treated them with kindness and respect.

People were supported with their medicines. Medicines were managed safely and people received their medicines from suitably trained, qualified and experienced staff.

People who could not make specific decisions for themselves had their legal rights protected. People’s support plans showed that when decisions had been made about their care, where they lacked capacity, these had been made in the person’s best interests.

The provider was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). The DoLS provide legal protection for vulnerable people who are, or may become, deprived of their liberty.

People received care and support from staff who had the appropriate skills and knowledge to care for them. New staff received induction, training and support from experienced members of staff. Staff felt supported by the matron and said they were listened to if they raised concerns.

The quality of the service was monitored regularly by the provider. Feedback was encouraged from people, visitors and stakeholders and used to improve and make changes to the service. Complaints were recorded, investigated and responded to in line with the provider’s policy.