CQC report explained · a residential care home
What the CQC found at Bridgewood House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had personalised risk assessments, staff understood safeguarding procedures and medicines were generally administered safely. Inspectors found that protocols for 'when required' medicines did not yet contain enough detail, and the manager began addressing this during the inspection.
- Effective?
- Good
- Staff had suitable induction, training, supervision and competency checks. The home supported people's nutrition, healthcare needs, communication and independence, and followed the principles of the Mental Capacity Act.
- Caring?
- Good
- People were treated with respect, patience and kindness. Staff understood people's preferences and communication, supported choices and protected privacy and dignity.
- Responsive?
- Good
- Care was person-centred and based on people's needs and preferences. People were supported with activities, family relationships, communication and end of life planning, although care plans were not always easy to navigate.
- Well-led?
- Good
- The home had improved its quality monitoring systems, with regular audits, service reports and clear staff responsibilities. Inspectors found a person-centred culture and good partnership working with health and social care professionals.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and person-centred care, with minor improvements still needed to medicines guidance and care plan layout.
This was an unannounced planned inspection on 10 March 2020. One inspector spoke with seven people, four staff members and reviewed care plans, medicines records, training records, audits and maintenance records. Observations were also used to understand the experience of people who could not communicate easily.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found improved risk assessments, enough staff, suitable training, safe medicines systems, kind interactions and activities that supported people's interests, relationships and independence.
The home had improved from Requires Improvement at the previous inspection, published in March 2019. Problems found previously with risk management, mental capacity requirements and quality monitoring had been addressed, although inspectors noted that 'when required' medicines protocols needed more detail and care plans were not always easy to navigate.
Improved safety systems
Risk assessments had been personalised and the home had sustained improvements made after the previous inspection. Staff knew how to respond to distress, anxiety and safeguarding concerns.
“At this inspection we were satisfied improvements had been made and sustained. The provider was no longer in breach of regulation 12.” from the report
Kind and respectful care
Inspectors saw patient and kind interactions. Staff knew people well, supported their choices and protected their privacy and dignity.
“People continued to be treated with respect, patience and kindness.” from the report
Activities and independence
People had individual activity calendars and were supported to use community facilities, maintain relationships and pursue their interests. The bungalows helped some people develop greater independence.
“People enjoyed a range of activities both at home and out in the community.” from the report
Skilled and supported staff
Staff received induction, specialist training, supervision and competency assessments. Training covered needs including epilepsy, catheter care and end of life care.
“Staff received an induction and training that enabled them to support people in a way that met their needs effectively.” from the report
Stronger management oversight
The provider had introduced regular audits, monthly service reports and clearer responsibilities. Inspectors found that the home learned from incidents and worked with other professionals.
“Since the last inspection there had been significant changes to the quality assurance systems.” from the report
Medicine protocols needed more detail
needs fixingThe instructions for 'when required' medicines did not explain enough about how one person communicated their medicines needs. The manager started correcting all these protocols during the inspection.
“We found the 'when required' protocols did not detail sufficient information to establish how the person communicated their medicines.” from the report
Care plans were difficult to navigate
needs fixingAlthough care plans were person-centred and reflected people's needs, essential information was not always easy to find. The manager said work was under way to improve the format.
“Although we found people's care plans were person centred, the plans were not always easy to navigate.” from the report
Rural location and agency staffing
minorThe home was in a rural location with limited public transport and had experienced recruitment and retention difficulties. Regular agency staff were used for a small number of shifts.
“There had been difficulties with recruitment and retention due to the service being in a rural area.” from the report
- 01Have all the 'when required' medicines protocols now been updated, and how do they explain your relative's way of communicating their needs?
- 02How will staff find the most important information quickly if care plans are still being redesigned?
- 03How many shifts are usually covered by agency staff, and how do you maintain consistent care for residents?
- 04How will you support visits and community activities given the home's rural location and limited public transport?
- 05What quality checks are now carried out regularly, and how are families told about improvements or concerns?
This was an unannounced planned inspection covering all five CQC questions, with the premises and care provided both considered; the previous rating was Requires Improvement in March 2019. This explanation was written from the published report of 21 March 2020 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, March 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but risks, records and quality checks needed stronger control.
Inspectors visited on 31 January and 4 February 2019. The first visit was unannounced and the second was announced. They reviewed care plans, medicines records, staff files, quality checks and building maintenance. They also spoke with people, relatives, staff and health professionals.
The home provided care for 18 people with learning and physical disabilities. Inspectors found enough staff, safe recruitment, a clean environment and kind care. People were supported with food, activities, healthcare, choice and independence.
However, some risk assessments and care records were incomplete or out of date. Medicines audits and wider quality checks were not strong enough. Some mental capacity and best interest records did not follow the required process. The home breached regulations about safe care and treatment and good governance.
The overall rating was Requires Improvement. Safe, Effective and Well-led were Requires Improvement, while Caring and Responsive were Good. The previous overall rating was Good, published on 19 July 2016.
Kind and respectful staff
Inspectors saw staff treating people with kindness, dignity and compassion. People appeared comfortable and relaxed with staff.
“Our observations during this inspection confirmed staff were friendly, kind and compassionate.” from the report
Enough familiar staff
There were enough staff to meet people's needs. Staff were recruited safely and formed a consistent team who knew people well.
“People were supported by a consistent team of staff who knew them well.” from the report
Clean and safe environment
The home was clean and well maintained. Staff had infection control training and equipment safety checks were carried out.
“The home was clean, tidy and odour free.” from the report
Choice and independence
People were involved in decisions and supported to choose activities, personalise their rooms and develop independence.
“Where relevant people's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Incomplete risk information
seriousSome risk assessments were generic and did not contain all the information staff needed. Emergency evacuation plans and moving and handling records also had gaps.
“Some risk assessments were not personalised and were generic with generalised risk reduction measures.” from the report
Weak medicines auditing
needs fixingInspectors saw medicines being given safely, but the audit did not identify two controlled drug count errors. Some medicines were also stored in the wrong type of cupboard.
“The medication audit was not robust or adequately detailed.” from the report
Out-of-date care records
needs fixingCare records were difficult to follow and did not always reflect people's current needs. The provider planned to introduce computers to improve this.
“As the service had no computers to update care plans, additions were often handwritten overwriting information.” from the report
Mental capacity records
seriousSome capacity assessments and best interest decisions did not show the options considered or follow the required legal process. One decision was referred to the local safeguarding authority.
“We found inconsistencies in the recording of capacity assessments and best interest decisions.” from the report
Quality checks missed problems
seriousAudits were limited and did not identify several issues found by inspectors. Policies also referred to out-of-date guidance and legislation.
“The range and depth of audits was limited.” from the report
- 01Have all care records been updated so they reflect each person's current needs, and how are changes checked?
- 02How are moving and handling risks, pressure ulcer risks and emergency evacuation plans now assessed and reviewed?
- 03What changes have been made to medicines audits and controlled drug storage since this inspection?
- 04How do you now record capacity assessments and best interest decisions to show that all options were considered?
- 05How do your current audits identify problems and show that improvements have been completed?
This was a scheduled inspection of the whole service covering Safe, Effective, Caring, Responsive and Well-led, with an unannounced first day and an announced second day. This explanation was written from the published report of 12 March 2019 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 Bridgewood House
3 rated inspections over 4 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 2010.
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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At least 100 live-in carers within about an hour of Kirklees
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 86 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“Primrose is a very kind and compassionate healthcare professional”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.