Bridlington Manor

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified a breach of legal regulations. Systems and processes to assess, monitor and improve the quality and safety of the service were either not operated effectively or were not in place. There was no evidence of continuous learning or systematic approach to improvement. Incidents were not reviewed for themes, patterns or for lessons that could be learned. Since December 2023 there had been 3 different managers in post. Some staff and a relative spoken with expressed concerns about the recent turnover of managers. There was not a registered manager at the time of our inspection. On our second visit a new manager had been in post for 3 days. A staff member told us, “I like [manager]. [Manager] is really nice and seems to be easy to approach if we need to.”

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with 2 managers and the provider. During our discussion there was no evidence of a shared plan of improvement or direction. The first manager left following our first day, the second manager had only started to work at the home 3 days before our second visit. All spoke with us about a recent local authority report detailing required improvements. The new manager confirmed they had not had time to implement actions or new systems.

Whilst the provider and both managers described to us some actions they were planning to take to make improvements, this had not been formulated into a structed improvement plan. The provider had not developed a timeline for improvements.

Since December 2023 there has been 3 different managers in post. There was not a registered manager at the time of our assessment. The previous registered manager had left, and a temporary replacement manager also left following our first visit. On our second visit a new manager had been in post for 3 days. They told us they had held one staff meeting and were planning meetings for relatives of people who lived at the home.

Staff spoke positively about the provider and the new manager. They said, “I like [manager]. [Manager] is really nice and seems to be easy to approach if we need to.”

Policies were in place to guide staff on how to raise concerns.

Staff felt supported and respected. Staff were aware of whistleblowing and told us they felt able to raise concerns. One said, “If someone is doing something that isn't right you whistle blow.”

Staff spoken with told us managers of the service were flexible in their approach to meeting staff needs and requirements. We received mixed feedback about how fairly staff felt they were treated. They said, “Sometimes feel valued. But not a lot, I do a lot and I don’t get paid enough for it” and “I feel I am treated fairly.”

There was no systematic approach to identifying staff’s equality, diversity or inclusion needs. However, staff spoken with did not raise concerns and said their individual needs were respected.

Systems and processes to assess, monitor and improve the quality and safety of the service were either not operated effectively or were not in place. A range of audits, governance and oversight systems had been in place, but there was no evidence of their systematic use after December 2023. For those completed they had not been used effectively to identify issues or take action to improve. They had not identified concerns found during this assessment. There was no effective overview or review of accidents or incidents for themes or patterns or for lessons that could be learned. Systems in place for identifying and recording staffing level needs had not been used effectively and dependency tools and rotas were not accurate. There was no evidence of checks of these documents. There was no evidence of audits or checks on the recruitment process. The provider had a checklist in place that identified the required checks and documents. Internal audits failed to identify that these had not been completed or that the required checks had not been undertaken. There was no system in place for ensuring people received person-centred care. There was no formal oversight of activities on offer for people or information about how people's preferences were been met. There was no plan in place to improve activities. Medicines were not managed safely. There were no records for medicines audits available and no recent staff medicines competencies. Systems that were in place for the oversight of the premises and equipment had failed to ensure action was taken to ensure health and safety and maintenance checks were completed. There was no formal provider improvement or action plan in place at the time of our visits. The manager and provider were aware of the recent local authority improvement action plan. Following the visits, the provider informed CQC that a range of oversight and audits had been put in place.

Care records were found to be inaccurate and incomplete. There was no system in place for ensuring people received person centred care. Managers confirmed there were no audits of care records available. They told us this was planned to start. The manager on first day told us 1 person was on a DoLS: this was highlighted on a newly developed handover sheet. Authorisation paperwork we found confirmed 7 people were subject to DoLS, all had renewal conditions in place. Care records did not accurately reflect authorised DoLS or conditions in place. A tracker used for oversight of DoLS was not up to date.

There were a number of health and social care professionals involved in people’s care to ensure the care they received met their health needs.

People we spoke with were mostly complimentary about their relationship with staff and managers, but they were concerned about the recent turnover of staff and managers. A relative told us it was, “Hugely disconcerting that 7 staff left before Christmas. The rapport with staff built over 2 years has gone.”

There was no evidence of a systematic approach to learning or sharing of good practice with outside agencies.

Some staff spoken with expressed concerns about the recent turnover of managers.

We discussed training with both managers during our visits. They both told us that training provided to staff needed to be developed further and additional courses provided including face to face training. They both told us they planned to book additional training, including fire safety, manual handling and first aid.

There was no evidence of continuous learning or systematic approach to improvement.