Bridgemead

The inspection was carried out due to concerns we received about the culture of the service. The inspection was also prompted in part by notification of an incident following which a person using the service sustained a grade 4 pressure injury prior to the provider taking ownership. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risks. These were in relation to people’s assessed needs, pressure wound management and personal care needs not being met. This inspection examined those risks.

We reviewed all quality statements in the 5 key questions of Safe, Effective, Caring, Responsive and Well-led.

We identified people’s outcomes were not consistently monitored. This was in relation to bowel and food charts, where we saw gaps in records. There were also gaps in some people’s records which showed they had not been repositioned in line with their care plan. The systems and processes in place to manage people’s risks were not always effective in identifying these concerns.

Temperature monitoring for medicine fridges showed gaps across several months which meant the provider could not always be assured medicines were fit for purpose at the point of administration. Emollient cream risk assessments were not always completed. The provider told us the steps they were going to take but this had not been embedded at the time of the assessment.

Although the service carried out recruitment checks, we identified gaps in 3 staff members employment history which had not been explored by the provider.

Menu choices did not always include information for people to plan their meals in advance and lacked detail about the vegetables and soup of the day options.

Staff provided mixed feedback about their wellbeing.

However, we found lessons were learnt to identify and embed good practice. People were safe and protected from abuse and avoidable harm. There were systems to support safe care pathways and transitions.

Staff had received training relevant to their roles and had mainly been recruited in line with legislation and policy.

The environment was safe and infection, prevention and control (IPC) was being managed effectively. Staff were knowledgeable about medicines processes. Medicines were administered as prescribed, with medicine administration charts (MAR) charts showing no missed doses of regular or high-risk medications.

People’s needs were assessed before joining the service. Staff and external teams worked well together.

People were treated as individuals, and we saw staff treating people with kindness, dignity and respect. There were plans in place to support people’s future care wishes.

Care plans we reviewed were evidence-based and contained information for staff to support people’s needs.

There was a shared vision, strategy and workforce equality, diversity and inclusion practices within the service. Leaders arranged regular meetings with people, relatives and staff

We found breaches of legal regulations relating to safe care and treatment and governance. We have asked the provider for an action plan to address these issues.