Bridlington Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified 3 breaches of the legal regulations. Care records were not always accurate or complete. They were not sufficiently detailed, personalised, or regularly reviewed. Risks to people were not assessed or managed safely. There were ongoing concerns with medicines management and administration. Records of internal environmental checks were not available. All required checks and maintenance to the buildings and equipment were not fully completed or current. There had been some improvements to the fabric of the building and decoration since our last inspection. All required pre-employment checks were not completed prior to people starting to work at the home. DoLS authorisations were in place, however managers and staff, were not aware who was subject to DoLS or what conditions were in place. Staff received some training but had not had any health condition specific training relevant to people's needs. We observed staff were patient and attentive to people, and interactions were friendly. Feedback from people and their relatives was mixed in terms of the consistency and abilities of staff at the home. People were supported in a timely manner. However, there was not a systematic approach to determining the number of staff required to be deployed to ensure people's needs were met and to keep them safe.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One person told us that if they raised any concerns with staff action would be taken. They said, “If I ever go up and ask about anything they do listen. They fit it in if it’s not going to be a danger to anyone.”

Staff were aware of procedures in the event of accidents and incidents. However, records of accidents and incidents had not always been completed by staff. One member of staff told us, “I would check [the person] over. If needed call 999 straight away. Keep them comfortable.”

Records of accidents and incidents were not all completed and there was no evidence of management oversight of actions taken to mitigate future risk.

People were supported to access healthcare, such as GP’s and district nurses.

Staff told us they were able to contact health care professionals when people needed. One said, “We phone the district nurse team if we need them. Speech and language therapist comes to see [person] around communicating.”

Both managers discussed with us the recent local authority improvement plan that had been put in place. At the time of our visits there was not a plan that indicated dates when the required improvements would be made.

Records reviewed showed staff supported people to access health care professionals when needed.

Everyone we spoke with felt safe at Bridlington Lodge. Comments included, “I always feel safe. Staff are wonderful and they always keep an eye out for us” and “I definitely feel safe. They [staff] are really good, and they help me. Yesterday I had a bath, and they used the hoist. Everything is safe.” People told us their visitors were made welcome.

Staff had a good understanding of their responsibilities to keep people safe from abuse. They were able to tell us how they would raise any concerns they had.

Staff and managers were all open and welcoming during the visits. People appeared to be comfortable living at the home, and in the company of staff supporting them.

Staff received training in safeguarding people from abuse. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. DoLS authorisations were in place. However, managers and staff working at the home during our visits, were not aware who was subject to DoLS or what conditions were in place. Staff had very limited knowledge or understanding of MCA and DoLS. Whilst we did not find evidence that DoLS requirements were not being met, it presented a risk that the requirements of MCA may not be met. We have addressed this in the well-led section of this assessment.

People we spoke with told us they felt safe and well cared for living at Bridlington Lodge. Relative and friends were generally happy with the care received. Comments included, "Staff know what they are doing and there are enough of them” and, “I am generally happy with [Names] care. [Name] appears well cared for, and always looks clean.”

Both managers we spoke with during the visits had only worked at the home for a few days. They were aware that some care plans were not accurate or up to date but had not reviewed them and neither had been aware of the specific concerns we found. The manager who started 3 days before our second visit told us they planned to audit care plans.

We observed staff supporting a person to mobilise and walk using walking aids. Another person was observed to be going out alone for a walk. Staff checked about their plans and safety in a respectful, gentle way.

Risks to people were not assessed or managed safely. Care records were not always accurate or complete. They were not sufficiently detailed, personalised, or regularly reviewed. This included care plans and risk assessments relating to health conditions nutrition, mobility, falls, medication, continence, skin integrity and finance. They did not provide sufficient guidance for staff to manage risks to people. There was no evidence people, or their families had been engaged with when planning their care or managing risk.

One person said of their bedroom, “Its lovely, I have a bed and all my bits and pieces. I watch TV in here after tea.”

Managers confirmed records of internal environmental checks were not available. The manager on the second day of our visit, told us they were going to introduce a daily walk round and environmental audit.

Since our last inspection some improvements to the fabric of building and decoration were noted. However, we noted during our walk round concerns regarding 4 freestanding wardrobes that were not affixed to the walls, this presented a risk that they could be pulled over. Portable electric heaters in 2 people’s bedrooms had been identified as needing risk assessments. Both these concerns were discussed on the first day but had still not been addressed by our second visit. A bath chair did not have a lap safety belt or risk assessment in place. This posed a risk that a person could slip out of the chair whilst being used.

All required checks and maintenance to the buildings and equipment were not fully completed or current. This included concerns with gas safety checks, portable appliance testing (PAT), legionella risk assessment, water temperature checks, environmental risks and internal fire safety checks. There was no current evacuation plan and staff were not trained in the use of fire evacuation equipment. No records of fire drills or tests were available, and staff spoken with during the visits were not aware of how to test or activate the fire alarm. Following this the provider and manager confirmed the gas certificate had been renewed, environmental risk assessments were in place and the wardrobes had been affixed to walls. They also confirmed the electric heaters were no longer in use and actions had been taken to ensure people would be safe in the event of a fire.

Feedback from people and their relatives was mixed in terms of the consistency and abilities of staff at the home. Comments included, “There are always staff about” and “Staff look after you very well but [night staff] are not trained, and don’t know what they are doing.”

Staff told us they were able to meet people’s needs in a timely manner. They said, “We have time to spend with people There is always 2 staff on the floor” and, “I feel there are enough staff to care for people.” Staff had not received regular formal supervision, but staff spoken with felt supported and able to raise issues with the manager or provider.

We observed calm and relaxed support during the visits. Staff were patient and attentive to people, and interactions were friendly.

All required pre-employment checks were not completed prior to people starting to work at the home. For 2 staff files reviewed one contained only a Disclosure & Barring certificate. No other evidence of the required checks was made available. Another file did not contain evidence of the person’s right to work in the United Kingdom. During our visits people were supported in a timely manner. However, there was not a systematic approach to determining the number of staff required to ensure people's needs were met and to keep them safe. Staff had received some training but had not received any health condition specific training relevant to people's needs. Staff had not received training in epilepsy or catheter care even though people with those needs were living at the home. Staff had limited knowledge or understanding of DoLS. The new manager told us training related to these topics was planned. There was a lack of formal induction and lack of systems for ensuring staff competency and knowledge were checked.

The people and relatives we spoke with did not raise any concerns with the cleanliness of the home. One person told us, “It’s a nice clean place and my room is beautiful.”

On the second visit the new manager told us they had identified an infection control audit was needed. They confirmed one had been completed following our visits.

Overall, the home, including some bedrooms and communal areas viewed, appeared to have improved in cleanliness and freshness since the last inspection. First floor communal hallways appear to be freshly painted and are bright.

The home was clean, and staff were aware of infection control and prevention measures. There were ample supplies of personal protective equipment throughout the home. The kitchen was visibly clean, but records relating to cleaning in the kitchen were not being kept.

People did not raise any concerns about their medicines with us. However, people’s medicines were not always given in the way prescribed for them. People did not always have medicines care plans to help identify and support their needs.

On the first visit, we discussed our concerns about medicines with the manager. They told us they would complete an audit of medicines and medicines records. On the second day, we found no medicines audit had been completed, as the manager had left and a new manager was in place. They told us they would arrange for a medicines audit.

We found ongoing concerns with medicines management and administration. Systems in place had failed to ensure the proper and safe management of medicines. Staff were not always following the provider's policy when giving medicines, therefore we were not assured medicines were given safely. We found errors in medicine stock quantities and records which meant medicines were not accurately accounted for. People who were prescribed medicine on an 'as required' basis did not have a protocol in place about when this medicine should be given. Staff did not always have accurate information, such as a body map, about how and where topical medicines should be applied. This meant people were at risk of not having their medicines as prescribed. Medicines were not always administered at the correct times. For example, medicines were not always given with food as instructed or medicines that were required to be given at a specific time were not always given correctly.