This inspection took place on 7 June 2018 and was unannounced.

Bridge Haven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Bridge Haven accommodates up to 53 people in one purpose built building. There were 36 people using the service during our inspection.

There was no registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had been appointed in December 2017, they had applied to CQC to become registered as the manager at the time of this inspection, but no decision had yet been made about their application. In the week following this inspection a decision was made to agree their application.

Bridge Haven was last inspected in April 2017. One breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified. We issued a requirement notice relating to safe care and treatment. We asked the provider to take action and they sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found improvements had been made, and the previous breach had been met.

At our previous inspection medicines were not consistently managed safely. At this inspection we found that improvements had been made and medicines were now managed safely. At our last inspection we recommended that the provider ensured sufficient staff were on duty to meet people's needs. At this inspection we found that staffing levels were safe and met people’s needs. People told us they felt there were enough staff and they didn’t have to wait long when they needed help. The manager had focused on ensuring there were enough staff by focusing on recruitment, looking at different ways of recruiting staff, such as open days.

People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. Staff knew about the whistle blowing policy and were confident they could raise any concerns with the provider or outside agencies if needed.

Equipment and the premises received regular checks and servicing to ensure it was safe. The manager monitored incidents and accidents to make sure the care provided was safe. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. The premises were designed, adapted and decorated to meet people’s needs and wishes. The manager told us about plans to further improve the environment for people; these included improving some outside areas and some of the communal areas.

Staff had completed induction training when they first started to work at the service. Staff were supported during their induction, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people's needs. There were staff meetings, so staff could discuss any issues and share new ideas with their colleagues, to improve people's care and lives.

Staff worked well together and ensured that clear communication between themselves and external health professionals took place; for example, with care managers, commissioners, GP's and district nurses.

The care and support needs of each person were different, and each person's care plan was personal to them. People had detailed care plans, risk assessments and guidance in place to help staff to support them in an individual

The inspection was carried out on 26 and 27 April 2017 and was unannounced. Bridge Haven is a large single storey accessible service located in a residential area of the village of Bridge on the outskirts of Canterbury and close to public transport links. There are parking restrictions in the surrounding area but the service has a large car park.

The service provides accommodation and personal care for up to 53 older people with dementia; there were 37 people in residence at the time of the inspection. The accommodation is provided on one level and this is divided into two units 'Primrose' and 'Bluebell'. One unit accommodates 29 people and one unit accommodates 24 peoples. Separate dining and lounge areas are provided in each unit but these are visible from each unit and people can move freely between these areas.

At our previous inspection of this service in September 2016 we issued an enforcement notice for Regulation 17 in respect of quality monitoring and quality audits; these were shown to be ineffective in identifying and addressing recurrent and new breaches of regulation. We required the service to be compliant with the enforcement notice by the end of December 2016. We also issued requirement notices in respect of regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 16 Receiving and acting on complaints and Regulation 18 Staffing. We asked the provider to send us an action plan of what improvements they intended to make to address these shortfalls. An action plan was sent to us when requested. Since the last inspection we received information of concern about staffing levels and some care practice issues at the service

Since the previous inspection the service had seen a change in its management team. A new manager and deputy manager were now in post. The new manager had applied to register with the Care Quality Commission and their application was in progress. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection highlighted that overall progress towards meeting the regulations had improved but further improvements were needed. The provider had taken all reasonable steps to address the staffing issues, however, there was a need for staffing to stabilise and improvements to be embedded and sustained over a longer period of time. We have made a recommendation about this.

People and their relatives were involved in the development and review of care and support plans including end of life wishes, this informed and guided staff about people’s needs and preferences. Relatives felt confident raising concerns and complaints were appropriately managed. People were able to make decisions and choices for themselves about how they spent their time, but there was no mechanism for recording their level of participation. People’s behaviour was monitored using an appropriate tool. However staff needed guidance on how to monitor this effectively to help inform the support they provided to people.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff sought people's consent on a daily basis. However, improvements were needed in how staff recorded people capacity to make decisions. We have made a recommendation about this.

During inspection the atmosphere in the service was calm and the majority of people were in positive moods; those who were not were appropriately supported by staff. People lived in a well maintained clean environment where equipment for their use and safety was serviced and checked regularl

The inspection was carried out on 26 and 27 September 2016 and was unannounced. Bridge Haven is a large single storey accessible service located in a residential area of the village of Bridge on the outskirts of Canterbury and close to public transport links. There are parking restrictions in the surrounding area but the service has a large car park.

The service provides accommodation and personal care for up to 53 older people with dementia; there were 42 people in residence at the time of the inspection. The accommodation is provided on one level and this is divided into two units ‘Primrose’ and ‘Bluebell’. One unit accommodates 29 people and one unit accommodates 24 peoples. Separate dining and lounge areas are provided in each unit but these are visible from each unit and people can move freely between these areas.

At our previous inspection of this service in July 2015 we found the service was not meeting the required standards in respect of staffing levels and staff training knowledge and skills. We took enforcement action to require the provider to address these shortfalls quickly, there were also additional breaches in a number of regulations and we asked the provider to tell us how they were going to address these. This inspection was to assess whether the improvements they had told us about had been embedded and were now everyday practice.

We had been informed that the registered manager had recently left. Interim management was being undertaken by the two deputy managers with support from senior staff in the organisation. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and relatives told us that they were satisfied with the quality and delivery of care provided in the service. Relatives did however, express concerns about recent turnover in staff, the need for agency staff to fill gaps in the rota and the impact this had on continuity of support for their own relatives. Professionals raised no particular concerns in regard to care delivery but some recognised the service needed support in some areas to up skill their staff and were now working with the service staff to improve awareness and provide training in areas such as skin integrity and end of life care.

Our inspection highlighted that whilst the provider had taken action to improve recruitment in the service this was not enough to ensure people received continuity of support from staff that understood their needs well and did not therefore meet previous enforcement action we had taken. Progress overall towards meeting previous shortfalls was disappointing with some continued breaches. We found that there was still a need to stabilise staffing and ensure the present dependency tool was suitable for the needs of the people supported. CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff sought people’s consent on a daily basis. A DoLS application had been authorised for a number of to ensure that they were not deprived of their liberty unnecessarily, however evidence of evidence of assessment of peoples capacity to make decisions was lacking within care records seen.

Risks were not always identified or measures implemented to reduce harm. Gaps in information held about people’s health conditions could place them at risk of receiving inappropriate support. The absence of a hand wash sink in the laundry could compromise staff maintaining good infection control standards. Recording around the action taken to address people’s minor concerns was lacking and did not meet the

The inspection was carried out by two Inspectors over one day. During this time we met and talked with people living in the service, the management team and care staff. We also observed staff supporting people with their daily activities. They helped answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Bridge Haven can provide accommodation for up to 53 older people, who may have dementia. There were 43 people using the service at the time of our inspection.

We considered our inspection findings to answer questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

This is a summary of what we found. This summary is based on our observations during the inspection, discussions with people using the service, staff supporting people and the management team and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Staff were able to identify when people may be at risk of abuse and knew how to raise their concerns inside and outside of the service.

There were systems in place to make sure that the staff learned from accidents and incidents.

Care was planned to ensure that people received safe and appropriate care. Care plans detailed each person's individual needs. When risks to a person were identified the service took action to manage the risk to them. However, more information and detail was required in some care plan records to support staff to provide safe and consistent care.

Is the service effective?

Staff knew people well, they responded to people’s requests and offered them choices. Staff knew what people were able to do for themselves and supported them to remain independent.

The provider operated an effective system to regularly assess and monitor the quality of the service provided. There were systems in place to ask people using the service, their relatives and staff for their views about the service and they were acted on.

Is the service caring?

People were supported by kind and attentive staff. Staff showed patience and gave encouragement when supporting people. People we spoke with said they liked the staff. Staff engaged with people positively when supporting them throughout our inspection.

The service worked closely with health and social care professionals to maintain and improve people's health and well-being.

Is the service responsive?

It was clear from observations and from speaking with staff that they had a good understanding of the people's care and support needs. Staff sought extra help and advice from other health and social care professionals when required.

Staff were attentive to people using the service and responded promptly when needed.

The management team ensured that adequate numbers of staff were on duty to meet people’s needs at all times.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities and that they felt supported by the new management team.

Staff rotas were planned to balance the number of agency staff and substantive staff, to ensure that staff who knew people well were always available to support them.

There was an effective system to regularly assess and monitor the quality of the service to protect people’s health, safety and welfare.

This was a responsive inspection following information of concern that we received about the care that was being provided to people who used the service. The concerns included lack of staffing, particularly at night, limited information in care plans about people's care needs, number of falls and people's care and welfare needs. We looked into how the service communicated between staff, with relatives and with health professionals, how often and how effectively care plans and risk assessments were updated and reviewed and we checked staffing levels to make sure that there were enough staff to meet people’s needs.

We found that when people who used the service had fallen, care plans and risk assessments were not always updated. The service did not monitor falls to identify trends or patterns.

Staff told us how they supported people who present as aggressive or anxious. However, there was no information in the care plans to provide staff with guidance.

We found that the service had taken appropriate action to obtain health care support for people when their needs changed and that referrals were made to the dietician and district nurses. However, we found that the care prescribed was not always followed.

The registered manager told us that they had recently recruited several new staff members and all vacancies were now filled. However, we found that there was not always enough qualified, skilled and experienced staff on duty to meet people's needs.

We found that the service did not have effective processes in place to assess and monitor the quality of the service the people received.

There were systems in place to ensure that there was communication between staff members, between shifts, relatives and professionals. We found that the provider had an effective system in place to receive, record, investigate and resolve complaints.

Some concerns were raised to us about the home. We looked into these concerns with a focus on how the service carried out assessments of people’s needs, how the service responded to any changing needs, how the service sought advice about aids, adaptations and equipment and how the service involved people and their loved ones in their care and treatment.

We also looked into how the service communicated between staff, with relatives and with health professionals, how often and how effectively care plans and risk assessments were evaluated and reviewed, how the service managed and responded to complaints and we checked staffing levels to make sure that there were enough staff to meet people’s needs.

We found that assessments were carried out and care plans and risk assessments were reviewed and updated. Advice had been sought from health professionals including doctors and district nurses, especially when a person became unwell or their needs changed. This had led to the provision of aids, adaptations and equipment so that people were more comfortable.

Care plans and other records showed that relatives and loved ones had been involved in assessments and care plan reviews. Some people or their relatives had completed a book entitled ‘About me’ giving written information about the person and their life history.

There were systems in place to ensure that there was communication between staff members, between shifts and between staff, relatives and professionals. We found that complaints had been recorded and responded to with procedures in place to try to resolve complaints.

We found that the high use of temporary or agency staff led to an inconsistency in care. One person said “They (agency staff) don’t know me. They don’t know how I want to be cared for. It’s alright for me; I can speak for myself and tell them. But some people can’t.” We found that recruitment to vacant care staff posts was underway and the manager said they hoped to get the vacancies filled soon. We will follow this up at the next inspection.

We met and spoke with some of the people using the service and to some relatives and a visiting health professional. We observed throughout the day to try to gain an insight into people’s experiences of the service. People told us or indicated that they were happy with the service. One person said “We are all very well looked after.”

People told us that the staff were kind and that there were enough staff to meet their needs. Staff spoke with people in a calm, positive reassuring manner. We saw a staff member hold a person’s hand to comfort them when they became upset and asked them if they were alright. The person smiled positively in response to this support. One person said “The staff could not be better.”

People maintained good health and mental health as the service worked closely with health and social care professionals. Activities were provided which were advertised and people had support to take part in meaningful activities and tasks.

People were treated with respect and their dignity and privacy maintained. People said they felt safe and had the care and support they needed. A visiting relative told us that they felt their relative was safe and had the care and support they needed. They said they were kept informed about their relative’s well-being and were always made to feel welcome when they visited the home.

We made an unannounced visit to the service to check on one compliance action we made at our last inspection. This involved parts of the care provided for one person to reassure them when they were distressed and to support them to dine in safety and comfort. We found that the compliance action had been met.

We saw that staff spoke to people who use the service with kindness and patience. The person who was the subject of the compliance action had complex needs which meant that they were not able to tell us directly about their experiences. Due to this we used a number of other methods to enable the person to express themselves. These included observing their general demeanour, interpreting sounds and movements and by noting the quality of their interactions with staff. The person concerned smiled and showed us that they were relaxed in the company of staff.

Other people who use the service said that that they were satisfied with the health and social care they received. They considered staff to be kind and helpful and they felt safe. One person said, “I like the staff because they’re all very kind to me and I like them being around because they help me.”

People who use the service said that staff treated them with respect and supported them to raise any concerns they had. They said that they received the health and personal care they needed and that they were comfortable in their home.

All of the six people with whom we spoke gave us positive feedback about the service. One of them said, 'I get on okay here with the staff and I get what help I need. The staff are nice people and they really do care about us all'.

People who use services said that the staff treated them with respect, listened to them and supported them to raise any concerns they had. They said that they received the health and personal care they needed and that they were comfortable in their home. One person said, 'I get on well with the staff. They're polite and okay with us. They're kind to us'.

The inspection was carried out on the 14 & 15 July 2015 and was unannounced. A previous inspection on 1 September 2014 found shortfalls in regards to record keeping. We asked the provider to take action to make improvements to record keeping in the service and they sent us an action plan that stated the provider would meet their legal requirements by 28 November 2014, but this action has not been completed.

Bridge Haven provides accommodation and personal care for up to 53 people living with dementia. At the time of our inspection there were 35 people living in the service. Accommodation is provided on one level and this is divided into two units ‘Primrose’ and ‘Bluebell’, one unit accommodates 29 people and one unit accommodates 24 people. Separate lounge and dining areas are provided for each unit but the open plan nature of the premises means that people can move easily between these areas. The premises are well equipped with plenty of equipment and bathing facilities. People have access to garden areas that are secure and easily accessible; a cabin in the grounds serves as a small tea shop where people can go with their relatives or with staff to have tea and coffee. The service is located in a residential location providing easy access to shops and public transport.

This service has not had a registered manager in post since October 2014; interim management arrangements were in place with additional support provided by senior managers. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection showed that people were not always safe and did not always get their needs met.This was because there were insufficient staff on duty to meet their needs and provide the assistance they needed.

Staff lacked a clear understanding of abuse and how to respond and report this appropriately; this placed people at risk of some incidents not being responded to consistently. Staff showed a lack of awareness in their everyday practice to health and safety hazards that could place people at risk of harm. Some important information about risks had not been developed in people’s care plans that would help staff recognise the signs and triggers they should be aware of to ensure they implemented the necessary risk reduction measures.

Information provided to inform staff in relation to emergency evacuation of the premises needed improvement to ensure staff knew what action to take and what equipment to use in the event of an evacuation of the premises, and what arrangements were in place for business continuity.

People and staff were at risk because guidance was not available to inform staff how to support people with behaviour that could be challenging. Records were not always well completed across a range of documentation and care plans did not always accurately reflect the support people were receiving.

CQC is required to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). The assistant manager showed she understood the responsibilities of the service to seek authorisations for people who may need some restrictions placed on their liberty. However judgements made by staff about people’s capacity to undertake everyday tasks or make decisions for themselves was poorly recorded within care plans to support their practice.

There was a low level of incidents recorded but these did not always include incidents recorded as part of behaviour monitoring, there was therefore a risk of under reporting of the number and range of incidents.

People left meals untouched because staff were not there to give them the prompting and encouragement they needed to stay and eat their food. The premises did not meet the needs of people living with dementia and there was a lack of signage to help them navigate their way around the home. The standard of cleanliness was not always to a good standard and equipment was not stored hygienically.

People were not provided with information about meals or activities in a format that was suitable to their needs or helped them make informed choices. The provider could not assure themselves that staff had the right knowledge and skills to deliver safe quality care to agreed policies and procedures because staff training was not up to date, there was a lack of assessment of staff competency and staff did not receive regular supervision. Improvements in staff competency for the administration of medicines were not sustained with a number of recurring medicine errors that could place people at risk of harm.

People were not provided with activities that met their needs. Relatives were given opportunities to express their views but did not feel their concerns were acted upon. People were at risk because the provider did not have an adequate system in place to assess and monitor the quality of care and treatment people received and to identify and act on shortfalls.

Staff said they felt supported and confident of raising issues with the assistant manager. They told us they had regular staff meetings to share information. New staff were provided with an induction that was in line with the requirements of the new care certificate. The required checks were carried out on staff before they commenced work.

People were supported to access healthcare for routine and specialist health care support, and records showed regular visits from GP’s and community nursing staff.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the full version of this report.