Archived: Burleigh House

Burleigh House is a residential care home providing accommodation and personal care to up to 15 people. The service provides support older people who may be living with dementia, mental health needs and/or a physical disability. At the time of our inspection there were 13 people using the service.

People’s experience of using this service and what we found

Medicines were not always managed safely as ‘when required’ medicines were not always administered in line with the prescription. There was often missing guidance for ‘when required’ medicines. Risks were not always assessed and planned for. Lessons had not always been learned when things went wrong, as action was not always taken when building safety defects had been identified. People were generally protected from cross infection, but the non-wearing of masks by some visitors (which was their own choice) had not been assessed. There were enough staff, so people were not unsafe, but further consideration was needed to ensure people had meaningful activity. Staff were overall recruited safely however further improvements were needed to ensure references were sought from most recent employers. People felt safe and were protected from the risk of abuse.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. One person on covert medicines did not have this fully assessed and reviewed.

Quality assurance systems were not always effective at identifying areas for improvement and at ensuring action was taken when concerns were noted. Building safety checks had not always been undertaken in a timely manner. The registered manager understood their duty of candour. People, relatives and staff were asked for their opinion. Relatives and professionals were positive about the registered manager and felt the service worked in partnership.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (report published 28 January 2021). At this inspection we found the provider remained in breach of regulations and remained rated requires improvement.

Why we inspected

We carried out an unannounced focused inspection of safe and well-led at this service in December 2020. Breaches of regulations were found in relation to safe care and treatment and ineffective monitoring systems. The provider was issued with warning notices for these breaches and had a deadline to be compliant by.

We undertook this focused inspection to check they had now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those breaches.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed and it remains requires improvement based on the findings of this inspection. We have found evidence that the provider still needed to make improvements. Please see the safe and well-led sections of this report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Burleigh House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and the monitoring of the quality and safety of care at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Burleigh House is a residential care home providing personal care to 11 people aged 65 and over at the time of the inspection. The service can support up to 15 people in one adapted building.

People’s experience of using this service and what we found

People’s risks were not always suitably assessed and managed and staff did not always have access to the information they needed to manage people’s risks. Medicines were not always safely managed and audits of medicines were not effective in identifying areas for improvement.

The provider did not have suitable systems in place to ensure areas of improvement were identified and acted upon. The registered manager was reactive to feedback but could not be proactive in their approach as they did not have suitable systems in place.

There were enough staff to meet people’s needs but there were gaps in the training staff had received. Staff knew how to safeguard people from abuse.

There were measures in place to prevent the spread of infections, however improvements were needed to ensure a robust approach.

People and relatives were happy with the care received and had confidence in the registered manager.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 10 January 2020) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for two consecutive inspections.

Why we inspected

We received concerns in relation to infection prevention and control practices, risk management and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report. The provider took immediate action to mitigate the most serious risks identified.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Burleigh House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit to check the provider has improved standards. We met with the provider prior to this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. If we receive any concerning information we may inspect sooner.

Burleigh House is a residential care home providing personal and nursing care to 12 people aged 65 and over at the time of the inspection. The service can accommodate up to 15 people in one adapted building.

People’s experience of using this service and what we found

Improvements were needed to ensure there were effective governance systems at the service and the provider had a clear oversight. Feedback sought from people had not always been acted on to make changes to the service. People were at risk of infection and harm because risks associated with the environment had not been mitigated. Improvements were needed to the way staff were deployed to ensure people received direct care and domestic tasks were completed as required.

People were protected from abuse because staff and the registered manager understood their responsibilities to protect people. Medicines were managed safely. The provider used safe recruitment practices and people’s individual risks were assessed and managed. Learning was taken from incidents and accidents to lower the risk of further occurrences.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported with their nutritional needs, and advice was sought from healthcare professionals to maintain people’s health and wellbeing.

People were supported by caring staff that supported people with patience. People’s choices were respected in line with their individual communication needs to promote informed decision making. People’s right to privacy was up held and their independence was promoted.

People had the opportunity to be involved in interests and hobbies. People understood how to make a complaint and there was a system in place to investigate and respond to complaints received. People’s end of life wishes had been gained to ensure their preferences were respected at this time of their lives.

People, relatives and staff found the registered manager was approachable and supportive. The registered manager worked with other professionals to ensure people’s needs were met.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 25 May 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to risks associated with the environment and governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor the provider’s progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People continued to receive safe care because staff understood how to protect them from avoidable harm and abuse. People’s medicines were managed safely to ensure they received their treatments at the right time and in the prescribed way. Staff’s suitability to work with people was checked before they were able to work in the home.

The care and support that people received continued to effectively meet their needs. People were provided with choices and when necessary they were supported by staff with their decision making. People were able to choose the food and drinks they enjoyed and were supported to have a sociable mealtime. When necessary people were referred to other healthcare professionals and staff followed the guidance they were provided with.

People’s experience of care remained good. Staff provided kind and compassionate care. People enjoyed the company of staff who protected their dignity and privacy. Relatives were welcomed into the home and supported to spend time with their relations.

Staff continued to respond to people’s needs. People were supported to spend their time as they wanted and staff respected their choices. Staff asked people about information that was important to them to ensure they received care in the way they preferred. People were encouraged to raise concerns or complaints and felt empowered to do so.

The service remained well-led. People and staff were given opportunities to learn about changes in the home which might affect them and were asked to share their feedback. The quality and safety of the service was monitored regularly. The registered manager understood the responsibility of registration with us.

Further information is in the detailed findings below

At a previous inspection completed on 2 August 2013 we identified areas of non-compliance with regulations we inspect against. We asked the provider to tell us how they intended to make improvements for the welfare and safety of people who used the service and when.

During this inspection, we checked if the provider had acted to improve the quality of service. We found some improvements had been made but further improvement was required. The provider need to ensure that suitable arrangements were in place for obtaining and acting in accordance with, the consent of people who used the service.

Is the service safe?

People who used the service were treated with dignity and respect. People told us they liked it at the home. One person who used the service told us, 'I like it here, it's very nice and I'm well looked after'. Another person told us, 'The lady who saw me made me feel welcomed. It made me feel like people are going to understand you here'. Safeguarding procedures were in place and staff understood how to safeguard the people they supported.

We noted that capacity assessments had been carried out for people judged not to have capacity to make specific decisions. Most staff had had received training on the Mental Capacity Act 2005 or training about Deprivation of Liberty Safeguards (DoLS) and were able to explain the principles.

Is the service effective?

People's care records were personalised, and the provider ensured that people's dietary, mobility and equipment needs had been identified in care plans where necessary. People who used the service said that staff spent time with them to understand their individual needs.

The provider needed to make further improvement to ensure that the records for people who should not be resuscitated (DNAR) indicated that other people who are involved in the care of the person had been involved in the decision. The records we saw during the inspection showed that only the doctor had been involved in making decisions about DNAR.

Is the service caring?

People were supported by kind, attentive and friendly staff. We saw that staff were caring and gave encouragement when supporting people. One person told us, 'I'm happy with the way they look after X. She's quite well looked after.' People told us that they did not have to wait for long if they needed assistance from staff. We saw that people were treated with respect and their dignity was maintained at all times.

Is the service responsive?

We saw that people were involved in a range of activities in and outside the service. People told us that they went out for day trips, and we noted that people were encouraged to engage in activities outside the service if they were able to do so independently. People knew how to raise complaints and we saw that complaints were investigated and dealt with appropriately. People told us that staff always responded to their needs in a timely manner.

Is the service well led?

The service worked well with other agencies and services to make sure care was joined up and effective. We saw records to demonstrate that identified shortfalls were addressed promptly. People we spoke with told us that the manager was also available to deal with any concerns. Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home. This helped to ensure that people received a good quality service at all times.

We found people using the service were safe because the staff were given clear instructions, support and guidance. People told us they were treated with care and compassion and the staff responded well to their needs or concerns.

We saw information regarding capacity and consent was not always in place. This meant the home could not demonstrate how arrangements to seek people's consent to care or treatment had been agreed in the person's best interests.

We saw people received a varied and healthy diet. People using the service spoke well of the food and were suitably nourished and hydrated.

At our last inspection on 3 January 2013 we made one compliance action about the management of medication. This meant the provider had to make improvements. We found that suitable and sufficient improvements had been made which meant medication was managed in a suitable and safe way.

Recruitment records demonstrated there were systems in place to ensure the staff were suitable to work with vulnerable people.

We saw people's confidential information was stored appropriately.

People told us they were satisfied with the care and support they received and were happy with the staff team that supported them. One person said, 'It is very nice, all the staff are pleasant.'

We found the care and support were delivered in a warm and caring manner. Records were informative and up to date.

We looked at the way medication was managed and saw that overall medication systems and practices were safe and suitable, but improvements were needed.

We looked at the number of staff on duty in the afternoon and considered the registered manager should judge whether there were enough staff available to meet the needs of the people using the service.

We found that complaints were dealt with quickly and appropriately and they were being recorded in the complaints register.