Bridge View

Bridge View is a care home providing accommodation and personal care with nursing for up to 61 people. At the time of the inspection, 53 people were living at the home.

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

People felt safe and told us staff were kind and compassionate. Safety monitoring was completed, which included fire safety. Any accidents or incidents were recorded and reported appropriately.

Medicines were managed safely. There were some issues with medicines paperwork which was being addressed.

Quality monitoring and governance procedures required some improvement. The registered manager and provider was addressing this.

Enough staff were employed to meet people’s needs and a safe recruitment system was in place. We have made a recommendation regarding recruitment of agency staff.

Activities took place within the home, but we have made a recommendation about tailored activities for those people on upper floors, particular those cared for in bed or those living with dementia.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the home supported this practice.

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

Rating at last inspection and update

The last rating for this service was good (published 12 February 2021). The service remains rated good overall.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

This report only covers our findings in relation to the Key Questions safe and well led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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 COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bridge View on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Bridge View is a residential care home providing personal and nursing care to 47 people at the time of inspection, some of whom were living with a dementia. The service can support up to 61 people in one large adapted building.

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

The quality and assurance systems in place were not effectively identifying issues and were not always completed. Records were not always completed or fully reviewed. The management team were reviewing the systems in place to make sure they were completed and suitable to monitor the quality and safety of care provided.

Lessons learned from incidents were shared verbally with staff. Improvement was needed in the recording of these. The manager assured us they would take action to address this record keeping issue.

Medicines were managed safely. However, associated records were not always accurately completed by staff. Other records did not always show regular monitoring of fluids for people who required this support.

Staff received regular supervisions from the management team. Training provision had been reduced during the pandemic. At the time of the inspection staff were in the process of completing on-line training sessions.

People told us they felt safe and happy living at Bridge View. Staff we spoke to enjoyed working at the service. Staff said they were able to provide feedback to the manager and felt supported. There was enough staff to safely support people.

There was an effective infection prevention and control policy in place and staff were following this to keep people safe. This had been reviewed and updated to reflect the current pandemic relating to COVID-19 and extra steps were in place to minimise the risk to people living at the home.

Records showed people and their relatives were actively involved in care planning and reviews.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 20 October 2018).

Why we inspected

We received concerns in relation to staffing levels, staff knowledge, people’s needs not being met, leadership and medicines management. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. We found no evidence during this inspection that people were at risk of harm from these concerns.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service has not changed. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe, effective and well- led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bridge View on our website at www.cqc.org.uk.

Follow up

We will continue to work with the provider following this report being published and monitor their progress and changes to ensure they improve their well-led rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Bridge View 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 View can accommodate 61 people in one adapted building across two floors. At the time of the inspection 51 people were resident, some of whom were living with a dementia.

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

We last inspected Bridge View in January 2018 and rated it requires improvement. We made five recommendations for the provider to review procedures and processes relating to:

• Diabetes management and ketone testing.

• Ensuring effective training was delivered to meet the needs of people at the service.

• Ensuring they follow the principles of the Mental Capacity Act 2005 (MCA) fully.

• The confidentiality of information.

• The governance procedures to ensure dates set for compliance are fully monitored.

During this inspection we found improvements had been made.

Detailed information in relation to the monitoring of diabetes and ketone testing were maintained. Care plans, risk assessments and emergency health care plans referenced specific health conditions and how they should be managed.

The provider had identified that the training provider was not appropriately meeting their needs and a new provider had been contracted. Some staff still needed to complete refresher training however a plan was in place to ensure all training the provider deemed as mandatory was completed by mid-December 2018. We have asked for an update on the progress of this.

The principles of the MCA were understood and were being followed. We discussed with the registered manager the need to ensure everyone who was involved in making a best interest decision was recorded. 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 in the service supported this practice.

The registered manager had completed training in the General Data Protection Regulations (GDPR) and had cascaded this information to the staff team. Information and records were stored securely.

Governance procedures had been reviewed and regular audits were completed which generated action plans to develop the service and ensure continuous improvements. A home development plan was also in place which was regularly updated with progress made against required improvements.

Staff were complimentary of the improvements made and the registered manager was open and responsive to feedback during the inspection and all areas where we identified minor improvements were needed were responded to immediately. The staff team were proactive in implementing this which we believe evidences a culture of development and learning.

Safeguarding, accidents and incidents, complaints and concerns were recorded, logged and investigated with outcomes and lessons learnt.

Risk assessments and care plans provided staff with guidance about people how to safely support people. Regular evaluations were completed but stated care records were ‘still valid.’ The registered manager and staff team responded to this immediately and on day two of the inspection detailed evaluations were being completed and recorded.

There were enough staff to meet people’s needs and safe recruitment practices were followed. All new staff completed a thorough induction and staff said they were well supported and felt the registered manager was approachable.

Premises and equipment checks and servicing were completed including gas and electrical safety.

Staff were knowledgeable of people’s nutritional needs, and a healthy balanced diet was provided with provision for vegetarianism and special diets. Food and fluid monitoring was in place and concerns responded to. People had access to healthcare professionals.

People said they were treated with kindness, dignity and respect. There were warm and caring relationships between staff, people and visitors and support was provided in a person-centred way. There was lots of laughter and engagement, with an unhurried, relaxed approach to providing care in a sensitive and discrete manner.

The service had been previously inspected in August 2017, where we found continued breaches of good governance, safeguarding service users from abuse and improper treatment, staffing and recruitment. We also issued a fixed penalty notice to the provider for failure to send notifications as legally required to the Care Quality Commission (CQC). The service at that time was rated overall as inadequate, placed in special measures and closely monitored.

We are currently conducting an investigation within our regulatory powers in connection with a death at the service in 2017. This continued at the time of the inspection.

Bridge View is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single packages under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Bridge View accommodates up to 61 people over two floors, each of which had separate adapted facilities. People had a range of support and care requirements, including those who needed nursing care and people living with dementia. At the time of the inspection there were 40 people living at the service, 23 of which were classed as ‘nursing residents’.

A new manager was in post who had applied to become 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We checked the procedures in connection with diabetes management and found that not all care plans had been followed as they should have been. This put people at potential risk of harm. We have made a recommendation about this.

Medicines management was suitable, with trained and competent staff administering medicines to people. The provider rectified a couple of issues we found during the inspection.

Safeguarding processes had been reviewed and staff were knowledgeable about what to do should they suspect or have any concerns about harm being caused to people. People told us they felt safe.

Accidents and incidents were recorded and monitored. Risks to people were identified and assessed to ensure that risk was minimised as much as possible. Fire safety and other building related checks were carried out to ensure the service was safe for people to live in. People’s emergency evacuation plans were in place to support an evacuation from the service should the need arise.

The service was clean and tidy and staff followed infection control procedures. The service was generally well decorated, and had a programme of continuous improvement.

There were enough staff in place and less agency staff used than in previous inspections. The manager ensured that agency usage was at a minimum. Staff felt well supported now and morale was much better than previous. The providers training programme was in need of review to ensure that staff had suitable and effective training in place. We have made a recommendation about this.

Recruitment was effective with safe working practices being followed, including receiving suitable references and obtaining Disclosure and Barring Service checks (DBS).

Food and refreshments at the service was good with positive feedback from people and their families. Special diets were catered for and support to people who needed it was given at the right times. Records in connection with this had been completed fully and in detail.

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 in the service supported this practice. Applications had been made for Deprivation of Liberty Safeguards (DoLS), where it was considered that people would be unable to keep themselves safe if they were to leave the home unaccompanied. We noted that some improvements were required in the recording of best interest decisions and the copies of lasting power of attorney details held. We have made a recommendation about this.

Healthcare professionals were fully involved with people at the service to maintain their health and wellbeing and this information was recorded. Referrals and appointments had been made with, for example, GPs, specialist nurses and occupational therapists. Any advice was used to support people’s care plans.

People told us that staff were kind and caring and knew them well. People were treated with dignity and respect. Independence was maintained. During observations we saw positive interactions between staff and people and their relatives. Care plans were person-centred, regularly reviewed and tailored around the individual needs of people and included information about people’s personal backgrounds.

People enjoyed the activities provided. There were stimulating activities for those wishing to participate and further new ideas planned for the future, particularly for those people who were living with dementia.

Complaints procedures were in place and people and their relatives knew how to complain and would not hesitate if they felt they needed to. They felt the new manager would respond positively to any issues raised.

Governance system were in place and evidence confirmed that the provider had identified concerns through these processes. However, we noticed that some issues found were still on going, for example recording of ‘as required’ medicines. We have made a recommendation regarding this. We also found that archived records were not always locked away securely. We have also made a recommendation about this.

People and relatives were very positive about the new manager and recent changes within the service.

The last inspection took place overnight on 16 May 2017 and we completed the inspection on 19 May 2017 which was announced. We found the service was breaching regulations, 13, 14 and 17, which related to safeguarding people, ensuring people received adequate nutrition and ensuring systems were in place to monitor the performance of the service. We rated the service as requires improvement in four key questions; is the service Safe? Effective? Responsive? and Caring? We rated the service as inadequate in one key question; is the service Well-led? The service had an overall rating of requires improvement.

We issued a warning notice in respect of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated activities) regulations 2014. We required the provider to take action and become compliant with this regulation by 25 July 2017. We served requirement notices for the other two regulations.

Since our last inspection the provider had sent us action plans and declared that all previous concerns had been addressed. We also made the decision to return to the service earlier than anticipated due to a number of anonymous concerns we had received and to check they were now meeting the regulations.

At a previous inspection in December 2016 we found the provider was breaching regulations 12, 17 and 18 in relation to safe care and treatment, staffing and good governance. We rated the service as requires improvement in four key questions; is the service Safe? Effective? Responsive? and Caring? The service had an overall rating of requires improvement. At March 2016 inspection we found the provider was breaching regulations 12 in relation to safe care and treatment. We rated the service as requires improvement in one key question; is the service Safe? At our first inspection, using this approach, in April 2015 we rated the service as requires improvement in three key questions and gave an overall rating of requires improvement.

Bridge View is spread over three floors, the ground and first floor providing nursing and residential care for up to 61 people, some of whom are living with dementia. At the time of our inspection there were 50 people living at the service.

The service has not had a registered manager in post since 26 June 2017. 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.

As at the last inspection we found that staff knew how to report safeguarding concerns. However, we found that safeguarding systems and processes were not effectively followed. Where safeguarding, complaints and staff disciplinary investigations had been undertaken, not all were robust enough to protect people fully.

There was a high use of agency staff and despite undertakings by the provider to ensure agency staff always worked with a permanent member of staff this was not occurring. On 17 August 2017 there were one permanently employed nurse, senior carer and staff member on duty with one agency nurse and four agency care staff. Two of the agency care staff had never worked at the service previously and because of numbers of available permanent staff worked together. No manager, deputy manager or regional manager were overseeing the service.

On 23 August 2017 we found that no manager or deputy manager was overseeing the service. A clinical lead had taken up post three days earlier and was completing their induction but due to staff shortages was working as the second nurse. They had not completed training around the use of the electronic medication system (WellPad) so could not administer medicines. The bank nurse was in charge of running the service that day although they told us that a regional manager was available to call if they had problems.

The procedures in place to ensure any agency staff deployed were suitable to work within the service were not robust. No monitoring checks were completed by the provider to check that agency nurses remained registered with the Nursing Midwifery Council or to see that people had the right to work in the United Kingdom and had completed appropriate training. We found that four agency staff were overseas students so entitled to work 20 hours per week but some were on the rota for 40 hours in a week and no checks were made to see what other work commitments they had each week.

The provider had systems in place to monitor the quality of the service provided and improvements had been made, but staff had not always followed procedures in line with the action plans they had sent us. On each visit but staff could provide us with ones completed in recent months. Following our last visit we asked to see the latest audits and on 29 September 2017 we were sent a range of action plans and several audits, such infection control and medication audits for the service that were completed in July 2017. All showed that issues were found at the service but the home development plan the provider sent to us in September 2017 indicated the majority were expected to be resolved. The home development action plan however did not pick up on issues we found, for example, that there was a lack of information about of incident and complaint investigations.

We were aware the provider had installed a computer system, which staff needed to use for recording their review of the service but staff could not show us any information held on this system. They were unclear if any action had been taken to record information on this system. We asked for the recent investigation and associated action plans plus information on how the provider was overseeing the management of staffing levels. None was provided. We considered quality assurance systems were not robust as they had not found the issues we had during the inspection.

We found four breaches in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and these related to safeguarding service users from abuse and improper treatment, good governance, staffing and recruitment.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Since our last inspection the provider had sent us action plans and declared that all previous concerns had been addressed. We returned to the service earlier than anticipated due to a number of anonymous concerns we had received and to check they were now meeting the regulations.

Bridge View is spread over three floors, the ground and first floor providing nursing and residential care for up to 61 people, some of whom are living with dementia. At the time of our inspection there were 57 people living at the service.

The service had a registered manager in post. 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.

Staff knew how to report safeguarding concerns. However, we found that safeguarding systems and processes were not effectively followed by the registered manager and provider. Where staff disciplinary investigations had been undertaken, not all were robust enough to protect people fully.

People received a range of food and refreshments to choose from. We received mixed views on the quality. We found staff did not always follow people's dietary needs as they should have been, for example, for those who were diabetic or on soft diets. Information which had been provided to kitchen staff and care staff was at times contradictory. This meant people were at risk of receiving inappropriate food to meet their needs.

We found a number of places within the service which were malodourous, although the service was clean and tidy in other areas.

Medicines were available as prescribed and were stored, administered, recorded and disposed of in line with best practice.

Accidents and incidents were acted upon, recorded and monitored appropriately.

People felt safe and their relatives confirmed they thought their family member lived in a safe environment and had no concerns with this aspect of care.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). Staff followed the requirements of the Mental Capacity Act 2005 (MCA) and DoLS.

People confirmed staff asked for their consent before embarking on any personal care and we heard examples of this during the inspection.

There were not enough staff in some parts of the service and the registered manager agreed and confirmed after the inspection that this had been immediately rectified.

The registered manager had procedures in place to ensure any staff recruited were suitable to work within the service. There was a training programme in place and staff development was monitored by the registered manager to ensure they had up to date knowledge and any training needs were met. The registered manager had procedures in place to ensure staff felt supported.

People told us they had access to health care professionals if they needed additional support. For example, GPs or community nurses.

During the inspection we heard positive interactions taking place between staff and people. However we did note two members of staff did not treat people in this way and this was dealt with promptly by the registered manager. We also considered practices we had found, including not following correct procedures was not conducive of a good caring service.

Care records were completed individually and regularly reviewed to ensure they met the person’s individual needs. Although there had been improvements in record keeping, we found some shortfalls which needed to be addressed and have made a recommendation to the provider.

People were not always given suitable opportunities to participate in activities tailored to their individual needs, particularly those people who were living with dementia.

People had choice to decide what they wanted to do on a daily basis.

People and their relatives knew how to complain. They told us they were able to meet with the registered manager and staff at any time and were able to give feedback about the service.

The registered manager held meetings for people and their relatives and surveys were sent out which meant feedback could be given in a supportive environment.

The provider had systems in place to monitor the quality of the service provided and improvements had been made, but staff had not always followed procedures in line with the action plans they had sent us. We considered quality assurance systems were not robust as they had not found the issues we had during the inspection.

We found three breaches in relation to Regulation 13, 14 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safeguarding service users from abuse and improper treatment, meeting the nutritional and hydration needs of people and good governance.

We made two recommendations in connection with activities, particularly for those living with dementia and checks on mattresses.

You can see what action we told the provider to take at the back of the full version of this report.

At our last inspection in March 2016, we found that the provider had not fully met the regulations and was in breach of Regulation 12, which was in connection with the cleanliness of the kitchen area. At this inspection, we found that improvements had been made.

Bridge View provides accommodation with nursing and personal care for up to 61 adults, including older people with physical and mental health difficulties and those living with dementia. At the time of our inspection there were 56 people living at the service.

There was a registered manager in post. 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. The registered manager was not present on the first day of inspection due to annual leave.

Complaints were now dealt with thoroughly by the registered manager; however we had found that one particular complaint had not been managed well by the provider organisation.

Record keeping within the service was in need of improvement. People who required their food or fluid intake monitored did not have this done in a way which meant staff could be assured that people had received correct levels of nutrition and hydration.

We found that people who were cared for in bed and needed support to move positions, due to their mobility, had not had this information fully recorded in their records. This meant staff could not be certain when the person was last moved or in which position they were previously in.

We found people’s drink thickeners where stored in unlocked cabinets within one of the dining room areas. As there is a risk of harm associated with these we asked a staff member to remove these straight away. Thickeners are usually powders added to foods and liquids to bring them to the right consistency/texture for people with swallowing difficulties.

The provider had recruitment and induction processes in place although we found the registered manager had not always ensured these processes were followed either before staff began work or once they had started their employment.

Quality monitoring systems were in place at the service and they had helped the registered manager identify areas which needed to be developed. However, they had not been effective enough to identify the concerns we had found in connection with record keeping for example.

After our inspection we wrote to the provider and asked them to send us an action plan as to how they intended to address our concerns, which they responded to immediately.

We found the service to be clean and tidy, particularly the kitchen area, which was unclean at our last inspection.

People were protected by staff who were aware of their safeguarding responsibilities. Staff had received safeguarding training and policies and procedures were in place detailing the process staff would follow to report any concerns they had. Since our last inspection, two safeguarding concerns had been upheld and one partially.

We received mixed views from people, their relatives and staff about whether they thought there was enough staff working at the service. They told us that at times it was busy. We were also told that call bells took a little longer to answer.

We observed staff carrying out their duties in a timely manner, other than early morning when staff were busy getting people up and ready for breakfast.

The home had implemented an electronic medicines management system since our last inspection. We found that people overall had received their medicines as prescribed as the registered manager monitored medicines closely to ensure they were in stock. However, we found that a small number of people did not have their medicines in stock on the day of the inspection and the regional manager was going to follow this up.

Risks in connection with people had been identified, including those in relation to care and support and the environment in which they lived. However, we found that some risk assessments, including those for bed rails and medicines, had not always been completed accurately or put in place.

Staff had received adequate training and had the knowledge and skills they required to do their job effectively.

Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. In England, the local authority authorises applications to deprive people of their liberty. We found the provider was complying with their legal requirements.

People’s nutritional needs were assessed and monitored. People were supported with any special dietary requirements, however, we received mixed views on the standard of the food provided.

People were able to see healthcare professionals outside of the home environment if they needed to. People told us that staff were effective in ensuring GP’s were called and they received support with hospital appointments.

We saw people being offered support if it was required and care staff did this in a way which retained the dignity of the people they were caring for. Care staff were seen to be kind and considerate. People told us they had choice and we saw people choosing what meals and drinks they would like.

People and their relatives felt that the staff at the service kept them up to date with information and enabled them to be involved with planning and review of their care needs.

A range of activities were on offer at the service and social isolation was addressed through the individual sessions held with people and via various events held within the service and at outside venues.

The provider continued to ask people and their relatives to complete surveys and attend meetings in order to gain their views on the service and to support them to ensure they delivered a quality service.

People and their relatives were complimentary about the registered manager and felt they could speak with her at any time.

The provider had recently made changes to the senior management team. There were new directors in post and there had been a reorganisation of head office teams dealing with, for example, the quality and governance of the organisation and human resource matters. This meant the provider would no longer use an external healthcare management support company to run the business.

New policies and procedures were being finalised and the provider was planning on rolling these out in the near future. This would provide managers and staff with current guidance in line with recognised best practice.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to safe care and treatment, staffing and good governance.

We have also made three recommendations in relation to food and drink and call bell procedures.

You can see what action we told the provider to take at the back of the full version of this report.

At our last inspection in April 2015, the safe, effective and well led areas required improvement, which meant the service, was overall rated as requiring improvement. At this inspection, we found that improvements had been made in all those areas, although we found additional issues that needed to be addressed in the ‘safe’ area.

Bridge View provides accommodation, nursing and personal care for up to 61 older adults. At the time of our inspection there were 40 people living at the service and made up of a mix of people, including those with more complex nursing care needs and those with a dementia related condition.

There was a registered manager in post. 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.

The kitchen area of the service was found to be in a dirty condition, and although the rest of the service was clean and tidy we considered this to be a breach of the regulations.

People were protected from the risk of abuse because staff were aware of the processes they needed to follow and we were confident they would have no hesitation in reporting any concerns.

The provider ensured that there were adequate numbers of staff available to meet people’s needs at all times by the use of a dependency tool and by close monitoring. Agency staff were currently being used, but the provider was in the process of recruiting to all vacant posts.

People received their prescribed medicines as required and the provider followed safe management practices. Although the medicines rooms were untidy this was in readiness for a new electronic system coming into use in the near future.

Staff had received adequate training (or were booked to receive) and had the knowledge and skills they required to do their job effectively. The provider had recruitment processes in place and practised these safely, although we have made a recommendation in this area.

Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. In England, the local authority authorises applications to deprive people of their liberty. We found the provider was complying with their legal requirements.

People’s nutritional needs were assessed and monitored to identify any risks associated with nutrition and hydration and had food they enjoyed.

People were supported to maintain good health because staff worked with other health and social care professionals when necessary.

Staff were kind and caring and knew people well. People were complimentary about the staff team and said they looked after them well. Relatives that we spoke with confirmed this.

People were cared for by staff who protected their privacy and dignity and who were encouraged to be as independent as possible.

The service was responsive because people and their relatives felt involved in the planning and review of their care and documentation had been put in place to support the recording of this action.

People had the opportunity to engage in group and individual social activities that they enjoyed and were supported to maintain relationships with their friends and relatives.

People were encouraged to offer feedback on the quality of the service and knew how to complain. The registered manager had dealt with the small number of complaints appropriately. We are currently reviewing information of concern which we have received about the location and are considering our enforcement options.

The provider had a wide-range of systems in place to assess and monitor the quality of the service and these worked well to identify shortfalls. The registered manager addressed any shortfalls found quickly.

Staff felt supported in their work and reported Bridge View to have an open and honest leadership culture at the service now.

People and their relatives knew the registered manager and thought she was ‘nice’. Staff reported the registered manager to be approachable and responsive to their requests.

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

We also made two recommendation to the provider in relation to recruitment and staff induction.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well- led?

On this inspection we looked at arrangements in place for the management of medicines and only assessed whether the service was safe in this regard.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

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

Is the service safe?

People told us that they were satisfied with the way their medicines were handled.

We found people were protected against the risks associated with medicines because the provider had improved arrangements in place to manage medicines. Medicines were recorded appropriately and showed that people received their medicines at the times they needed them.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from and looking at records.

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

Is the service safe?

People living in the home told us that they had no concerns about their medicines. However, we found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the safe administration, recording and handling of medicines.

This is being followed up and we will report on any action when it is complete.

You can see our judgement on the front of this report.

People told us that they were not always observed by staff when they consumed their medicine. Staff told us that on some occasions, they had found tablet medication that was not in a container, on surfaces within communal areas. We looked at the recording of the administration of people's medication and found that people were not protected against the risks associated with medicines, because this was not always accurately recorded.

We have passed our concerns on to a pharmacist inspector who will visit the home to follow up these concerns in due course.

We found that people's care and support needs were appropriately assessed and their care and support was planned. Where people required input into their care from external healthcare professionals this had been arranged.

People received care which reduced the risk of poor nutrition and dehydration. Where necessary, external healthcare professionals had been consulted about people's dietary concerns.

We saw that people had enough equipment available to enable them to maintain their independence as much as possible and this equipment was suitably maintained.

However, we identified shortfalls in respect of medicine management which meant that people's health and welfare was put at risk.

At this inspection we also checked whether previous shortfalls in relation to staffing had been addressed. We found improvements had been made and the risks associated with staffing had been reduced.

People told us their consent was gained prior to care being delivered and we found that staff acted in accordance with their wishes. Where appropriate we found the provider acted in accordance with legal requirements where people did not have the capacity to consent themselves.

We found that people's care and support needs were appropriately assessed and their care was planned. They received care safely and to an appropriate standard.

People were cared for in a clean and hygienic environment and we found that the service had appropriate measures in place to monitor and manage infection control.

We saw the provider had a complaints policy and procedure in place and people told us they would confidently raise any concerns they had with the manager.

However, we found that failures to manage staffing appropriately meant there were not enough suitably skilled and qualified staff on duty to met people's needs safely and appropriately.