CQC report explained · a nursing home
What the CQC found at Bridgeway Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found unsafe medicines management and gaps in oversight, although people were supported by consistent staff and a positive culture.
Inspectors made an unannounced visit on 8 June 2022. They spoke with people, relatives and staff, and checked care plans, medicines records, safety documents, audits and policies. They looked only at Safe and Well-led.
The home was not always safe because medicines and thickening products were not managed properly. Records did not always show the right instructions or amounts, and some creams did not have opening dates. Inspectors found no harm, but said people were at risk. They also found a recruitment check gap and audits that had not identified the medicines problems.
There were enough staff to keep people safe, infection control was good, and people and relatives generally spoke positively about the care. The overall rating changed from Good at the previous inspection to Requires Improvement. The provider was asked for an action plan and will be monitored.
Consistent staff
People were supported by staff who knew them well, and staffing levels were considered adequate to keep people safe. The home did not use agency staff.
“There were adequate staffing numbers to keep people safe and the service did not use agency staff.” from the report
Infection control
Inspectors were assured that the home had suitable measures for preventing and managing infections, including safe visiting and use of protective equipment.
“People were protected from the risk of spread of infection.” from the report
Positive culture
People and relatives gave positive feedback. Staff said they enjoyed their work, and inspectors found a person-centred culture.
“People benefitted from a positive and person-centred culture at Bridgeway Care Home.” from the report
Involvement and communication
Relatives were kept informed, and people, relatives and staff could give feedback through meetings and reviews.
“There were regular resident's meetings, and review meetings with relatives.” from the report
Medicines and thickener
seriousThickener was left unsecured, instructions were not clear in shared areas, and staff did not record how much was used. This created a risk of harm, including choking risks.
“This meant there was a risk the wrong amount of thickener could be added to a person's drink.” from the report
Medicines audits
needs fixingThe home's medicines audit did not identify the unsafe practices found during the inspection. Inspectors recommended that auditing should be improved.
“The medicines audit did not highlight issues about the safe management of medicines that we found during this inspection.” from the report
Recruitment checks
needs fixingOne staff member's Disclosure and Barring Service check had been completed for a previous employer and had not been repeated for the current employer. The provider applied for a new check after inspectors raised this.
“There were safe staffing levels at the home although there were gaps in recruitment processes.” from the report
Opportunities to go out
minorSome people and relatives said staff were busy and that more staff would help people go out and take part in activities.
“I don't go out very much as there does not seem to be enough staff.” from the report
- 01What changes have you made to keep thickener locked away and to give staff clear instructions?
- 02How do you now record the amount of thickener added to each person's drink?
- 03How do you check that topical creams are dated when opened and discarded safely?
- 04What has changed in your medicines audits since this inspection, and how do you make sure problems are acted on quickly?
- 05Have all staff recruitment checks, including the Disclosure and Barring Service check identified in the report, now been completed?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and were carried over from the previous inspection. This explanation was written from the published report of 15 July 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2021
Rated Good; inspectors found safe, respectful care, but some accident and quality-monitoring records were not detailed enough.
This was an unannounced focused inspection on 29 and 30 June 2021. Inspectors looked only at Safe and Well-led because concerns had been raised about people's nursing care needs. They spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse, staffing levels were sufficient, medicines were given as prescribed and infection-control arrangements were satisfactory. Staff worked with health professionals and supported people in a respectful and person-centred way.
Some accident and incident records did not clearly show what action had been taken or what had been learned. Quality audits also did not always contain enough detail to identify patterns. Inspectors made recommendations to improve these records, but found no evidence that the concerns about nursing care had put people at risk of harm.
The overall Good rating includes ratings carried over from the previous comprehensive inspection for the questions that were not examined this time. The previous overall rating was Good, published on 20 June 2018.
Safe recruitment and staffing
The home completed suitability checks and maintained enough staff to support people during the day and night.
“The provider had recruited staff in a safe manner and completed necessary checks of suitability to ensure people were fit to work with vulnerable people.” from the report
Medicines
People received their medicines at the right time and as prescribed. Staff who gave medicines had suitable training.
“People received their medicines when they should and as they had been prescribed.” from the report
Respectful, person-centred care
Inspectors found staff treated people positively and respectfully, with a focus on their individual outcomes and independence.
“The provider and staff interacted with people in a manner that was positive and very respectful and were focused on doing their best for people they supported.” from the report
Working with health professionals
The home worked with health professionals and multidisciplinary teams to support people's care and outcomes.
“Staff worked effectively in partnership with health care professionals from multidisciplinary teams to achieve good outcomes for people.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infection, including the use of protective equipment and support for visits.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Accident and incident records
needs fixingSome records did not clearly show all actions taken or whether lessons had been learned. Inspectors recommended improving how these events are recorded and reviewed.
“However, the records used were not always completed in full.” from the report
Quality audits
needs fixingSome monitoring records were not detailed or effective enough to make patterns and themes easy to identify. Inspectors recommended improving the recording and analysis of audits.
“However, some documentation used was not always detailed enough or completed effectively.” from the report
- 01What changes have you made to ensure accident and incident records show every action taken and the lessons learned?
- 02How do you now use audits to identify patterns and themes in quality and safety?
- 03What arrangements are currently in place to make sure there are enough staff on duty day and night?
- 04How do you involve people and their families in regular reviews of care needs?
- 05Which ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 19 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bridgeway Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- July 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Goodstayed GoodSafe: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Registered with the Care Quality Commission on 4 August 2014.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £980 to £1,260 a week. 78 can care for a couple. 11 years' experience on average.
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