Archived: Burlington Care and Support Services

About the service

Burlington Care and Support Services, referred to as Burlington House, is a residential care home that provides personal care and support for up to 13 people with a learning disability. At the time of the inspection there were 10 people living at the service. Accommodation is provided over two floors within two separate but adjoining buildings.

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

People told us they felt safe, they liked living at Burlington House and most relatives we spoke with did not raise any concerns about the care their loved ones received.

We found the service was not operating in accordance with the regulation and was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture and best practice guidance. This meant people were at risk of not receiving the care and support that promoted their wellbeing and protected them from harm.

Right support:

People were not always supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible and in their best interests. People were not involved in a meaningful way in the development of their care and support and information was not always provided in a way which met people's individual communication needs

Right care:

Care was not always provided in a person-centred way which promoted people’s dignity, privacy or human rights. People’s care and support plans were not always reflective of their range of needs, supported their aspirations, or promoted their wellbeing and enjoyment of life.

Right culture: The ethos, values and attitudes of managers did not always ensure people using the services were enabled to lead confident, inclusive and empowered lives. Staff understood their role in making sure that people were always put first, but care and support was not always tailored to their individual needs and preferences.

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 14 December 2019). Following that inspection, the provider was asked to complete an action plan to show what they would do and by when the improvements would be made. At this inspection we found the provider remained in breach of regulations and has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. 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.

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 Burlington Care and Support Services 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 monitor the service and will take further action if needed.

We have identified breaches in regulation in relation to safe care and treatment, recruitment, staffing, the need for consent, dignity and respect, person centred care, notifications of other incidents and governance.

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

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We will meet with the provider following this report being published and work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Burlington Care and Support Services, referred to as Burlington House, is a residential care home that provides personal care and support for up to 13 people with a learning disability. Accommodation is provided over two floors within two separate but adjoining buildings. At the time of the inspection there were 11 people living at the home.

Burlington House had been developed and designed prior to Building the Right Support and Registering the Right Support guidance being published. Burlington House was a large home, bigger than most domestic style properties. This is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

People’s experience of using this service:

People told us they were happy and liked living at Burlington House and staff were seen to be kind, caring and respectful of people’s needs.

Relatives continued to provide positive feedback about the care and support people received. One relative said, “Whenever I visit I’m always impressed by the individual attention my family receive and feel they are in a safe and supportive environment.”

We found improvements had been made in all areas of the service over the six-month period since the last inspection, but further improvement was required, and the timeframe did not allow for sustained improvement to be evidenced.

People were not always 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.

Staff were not provided with appropriate training, necessary for them to undertake their role. We discussed what we found with the provider who confirmed some courses had been booked and others were planned.

People’s care records contained good information about people’s goals and future aspirations, however we found there was little information to show how people were being supported to achieve them.

People’s medicines were stored and managed safely, however we found some aspects of medicines recording could be improved.

People, staff and relatives felt there were enough staff on duty to support people and keep them safe. However, we were unable to tell from the rota if there were sufficient staff on duty to meet people’s needs. We have recommended the provider reviews staffing levels.

People were protected from the risk of avoidable harm.

People were protected by safe recruitment processes. Systems were in place to ensure staff were recruited safely and were suitable to be supporting people who might potentially be vulnerable by their circumstances.

People were encouraged and supported to maintain links with the community to help ensure they were not socially isolated.

People were encouraged to share their views and people told us they were aware of how to make a complaint.

People and their relatives had confidence in the service and told us the home was well managed. The provider had increased their level of oversight and lessons had been learnt from past inspections.

The service was clean, staff had access to personal protective equipment (PPE) and there was a plan in place to make the necessary environmental improvements as detailed in the services refurbishment plan.

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 on 11 April 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Following the inspection in January 2019, we issued a ‘notice of decision’ to impose a condition on the providers registration. This required the provider to undertake a review of the quality assurance systems in place and carry out monthly audits in respect of pressure area care, risk assessments, medicines management, care planning, service users’ rights and social care needs including activities, socializing with others and outings.

The provider was required to send to the Care Quality Commission a monthly report confirming the dates on which these audits had taken place, and include the actions taken or to be taken as a result of these audits to demonstrate that any areas of risk were being properly identified, assessed and mitigated. In addition, the provider was required to carry out an audit to ensure the premises were clean, suitable for the purpose for which they were being used and properly maintained. This information was to be used to establish a comprehensive refurbishment plan which the provider was required to send to the Care Quality Commission monthly, detailing any updates/progress.

At this inspection we found not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to the need for consent and staff training. We have also made recommendations in relation to, staffing levels and governance. Please see the action we have told the provider to take at the end of this report.

Follow up:

This is the fourth consecutive time this service has been rated ‘Requires Improvement.’ 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 work alongside the provider and local authority to monitor progress. In addition, we will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

People’s experience of using this service:

We found the service was not operating in accordance with the regulation and best practice guidance. This meant people were at risk of not receiving the care and support that promoted their wellbeing and protected them from harm.

The provider did not have sufficient oversight of the service to ensure people received the care and support they needed that promoted their wellbeing and protected them from harm. Systems and processes to monitor the service were not effective and did not drive improvement. These included concerns with records, risk management, medicines, a lack of person centred care, infection control and the environment.

Staff told us people were encouraged and supported to use a range of healthcare services. We found the service were slow to seek advice or make referrals when people’s needs had changed.

Whilst we did not find people were being disadvantaged, people were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible. Related assessment and decisions had not been properly undertaken. Where some people were subject to continuous supervision the provider had not applied for this to be authorised.

Staff felt supported and valued and received regular training. However, there was a lack of monitoring of this training to check if it was effective.

People told us they felt safe and well cared for. Staff afforded people respect and provided care and support with compassion. Relatives did not raise any concerns about people’s safety and told us people were well cared for and looked after.

People and their relatives had confidence in the service and told us the home was well managed. One family member said, “I have no concerns about how the home is managed.” Another said, “My experience has been a positive one, I have always found the manager and staff to be incredibly helpful.”

Rating at last inspection: The service was previously rated as ‘Required Improvement.’ The report was published on the 16 February 2018.

Why we inspected: This was a planned inspection that was scheduled to take place in line with Care Quality Commission scheduling guidelines for adult social care services

Enforcement: We found repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have also made recommendations in relation to staffing levels, training and infection control. Please see the action we have told the provider to take at the end of this report.

Follow up: This is the third consecutive time this service has been rated ‘Requires Improvement.’ 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.’ In addition, we will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

The registered provider is also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run. The provider was supported in the management of the home by a service manager, who was in day to day control.

The home has been established for many years and was working in line with the values that underpin the Registering the Right Support. These values include choice, promotion of independence and inclusion, although the home did not always record how this was being done. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

Burlington House was previously inspected in December 2016 and was rated Requires Improvement. At that time we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have effective systems to manage risks to the people’s safety and welfare and had not notified the Care Quality Commission (CQC) of important events within the home. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to meet the requirements of the regulations. The provider confirmed that personal emergency evacuation plans and risk assessments for each person would be reviewed and rewritten as necessary and that CQC would be notified of all important events in the home that affect people’s safety and well-being. Since the last inspection, the home has kept CQC informed of events in the home. However, at this inspection in January 2018, we found improvements were still required to ensure people received safe care, with record keeping, people’s dignity was not always respected and systems were not effective in monitoring the quality and safety of the service.

Staff were able to describe people’s needs and knew how to keep people safe. However, this level of detail was not recorded in people’s risk assessments or support plans. Records relating to the management of risks to people’s health, safety and well-being were either insufficiently detailed or staff actions were not being fully documented. For example, one person’s risk assessment failed to guide staff about how to support the person at times of anxiety when they were at risk of self-harm. For another person, the actions taken by staff to ensure the person was safe when out of the home were not well documented. We found that not everyone’s dignity as being respected. One person had particular night time support needs and we found their room had an unpleasant odour. Although the provider told us the room was regularly cleaned, the odour remained. In addition, staff had placed plastic ‘clinical waste’ bags on one area of the person’s floor.

The provider did not have effective systems in place to assess, monitor and improve the service. Although they attended the home at least once a week, they did not have a system of documented audits or reviews to demonstrate their oversight of the home. They had not identified the improvements required in the risk assessments and support plans to ensure people received safe and consistent care and support, or that one person’s dignity was not being respected. With the exception of manageing fire safety well, regular audits of the safety of the environment, such as hot water temperatures, were not being undertaken. Some improvements to the environment were also required, for example, a number of carpets were wearing thin and fraying.

People told us they were supported to be as independent as possible. However, we found no reference in people’s support plans about how their independence was being promoted or their future gaols and aspirations. Support plans were insufficiently detailed to ensure people’s abilities, goals and preferences were recognised and supported in a consistent way.

People received their medicines safely and as prescribed. People were supported to use a range of health care services and had regular contact with dentists, opticians and GPs. Where necessary specialist advice had been sought from the learning disability community services.

People told us they felt safe living at the home and they were well supported by staff. One person said, “Yes, it’s the best place to live.” People knew how to make a complaint and told us they had no concerns. Throughout the inspection we saw staff and people interacting in a friendly and respectful way. People’s rights to make decisions and choices about their lives and the support they received were respected. Where necessary, for those people who were unable to make these decisions, capacity assessments had been undertaken and decisions made in their best interests.

Records showed and people told us they were involved in a variety of activities in and out of the home. Each person had a keyworker with whom they planned activities. People’s support plans held an activities planner for the week. During the inspection we saw people coming and going from the home and involved cleaning, laundry and meal preparation either independently or with staff support.

Staff were safely recruited and provided with the training they needed to undertake their role. They had regular supervision and appraisal of their work performance and were able to share their views about the home. Sufficient numbers of staff were provided to meet people’s needs and to support them in leisure and social activities.

We identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and made one recommendation for improvement.

You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on the 9 and 13 December 2016; the first day of our inspection was unannounced. One adult social care inspector carried out this inspection. Burlington House was previously inspected in May 2014, when we found the provider did not have effective systems to identify, assess and manage risks to the health, safety and welfare of people or to regularly assess and monitor the quality of service provided. At this inspection, we found that although some improvements had been made further improvements were needed.

The registered provider is also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

Following our last inspection, the provider had introduced a new quality auditing system. We found this had introduced some improvements but was not fully effective to assess and monitor the quality and safety of the services provided at the home. Although some systems were working well. risks to people's health and wellbeing had not always been identified, assessed or mitigated. People’s individual needs were not always assessed or planned for. Whilst support plans and risk assessments reviews were taking place monthly, these had not identified the lack of information or instruction for staff in how to meet people’s needs. Where people had specific needs relating to their behaviour or lifestyle choices, risk assessments did not identify the risk of potential harm to other people living at the home, the person, or contain guidance for staff on how to manage these risks.

We looked at the personal emergency evacuation plans (PEEP) which were in place for people who lived at the home. The purpose of a PEEP is to ensure staff know how to assist each person to leave the building safely in the event of an emergency. We found these had not been completed for all people currently living at the home. This meant staff did not have all the key information they needed to assist people from the building in the case of an emergency.

We have made a recommendation that the provider keep the system for identifying risk and mitigating risk under review.

The registered manager had not always notified the Care Quality Commission of significant events, which had occurred in line with their legal responsibilities; this included the notification of safeguarding concerns.

People said they felt safe and well cared for at Burlington House; their comments included “I do feel safe,” “I’m very happy,” “It’s my home, and I like it here.” Relatives told us they did not have any concerns about people’s safety.

People were protected from the risk of abuse. The registered manager had developed an easy read document, which told people how they could seek advice or raise a concern. Staff had received training in safeguarding vulnerable adults and demonstrated a good understanding of how to keep people safe. Recruitment procedures were robust and records demonstrated the home had carried out checks to help ensure staff employed were suitable to work with people who are vulnerable due to their circumstances. Everyone we spoke with felt the staff were well trained and able to meet their needs.

Staff showed a good understanding of the Mental Capacity Act 2005 (MCA) and their role in maintaining people’s rights to make their own decisions. During the inspection, we observed staff putting their training into practice by offering people choices and respecting their decisions. People were involved in their care and support, attended regular reviews, and had access to their records.

Although we noted some inconsistencies in people’s care records, as detailed within the ‘Safe’ section of this report, People's support plans were informative, detailed, and designed to help ensure people received personalised care. Support plans were reviewed regularly and updated as people's needs and wishes changed. People were supported to follow their interests and take part in social activities. People received their prescribed medicines on time and in a safe way. There was a system in place to monitor the receipt and stock of medicines held by the home. Medicines were disposed of safely when they were no longer required. Staff had received training in the safe administration of medicines.

People told us they enjoyed the meals provided by the home. People told us they were involved in planning the menu and we saw care staff supporting people to choose what they wanted to eat. Where people required a soft or pureed diet to reduce the risk of choking, this was being provided. Staff were aware of people's preferences, nutritional needs and allergies. People were freely able to access the kitchen to make drinks and snacks if they wished.

People, relatives, and staff spoke highly of the service manager and registered manager, and told us the home was well managed. Staff described a culture of openness and transparency where people, relatives and staff, were able to provide feedback and raise concerns.

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

Below is a summary of what we found. The summary describes what people using the service their relatives and the staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

The people living at Burlington House valued the feeling of safety that the service gave them. People we spoke with told us that they felt safe at the home. They explained that the staff from the home would go out with them if they felt unsafe being in the community on their own. Others told us that the home had systems in place to keep a check on their safety if they were out alone. Staff and management were aware of proper safeguarding systems and knew what to do in the event of a safeguarding matter.

We were concerned to see a person apparently struggling with their mobility. However, the managers were able to explain what systems they had introduced to maintain the person's safety. The provider might find it helpful to note that no consideration of a professional assessment had been made.

The management and staff of the home were aware of their responsibilities under the deprivation of liberty safeguards (DoLS). They told us that at the time of our visit no one was subject to these safeguards. This was confirmed by some of the people who lived there, who told us that it was their informed choice to only go out with staff. For example, one person said "I would like to go out on my own, but I would have to learn how to."

Is the service effective?

Every person we spoke with told us that they liked living at the home. One person told us that it was "Lovely. Everything's good here." Another said "I like it here, this is my new home. I like Burlington House. I like it. I like the staff. I am happy here." It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. One member of staff told us "We give the guys what they want, rather than what we want. It's their home. They are a very different set of people, each with their own issues." Staff had received training to meet the needs of the people living at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that the staff were patient and gave encouragement. For example, one member of staff asked "have you tidied your room?" as a reminder of what the person was supposed to be doing. Another person told us that staff helped them to wash their hair and back.

We saw a card sent by a relative which commented on how much better their relative was since being at the home.

We met a visiting professional who had referred one person to the home and was in the process of making a second referral. They told us that the staff 'seem very friendly" and that their client "seemed relaxed."

Is the service responsive?

We heard how managers had attended meetings prior to a person moving into the home. This meant that they knew what to expect when the person arrived. We also saw, from entries on a log sheet, that a member of staff had attended best interests meetings for one person. This meant that the home was able to participate in making an important decision on the person's behalf.

Is the service well-led?

The home was managed by the Registered Manager, who was also the owner of the home. She was assisted by a full time service manager. We heard the staff and people living at the home speak highly of the managers. However, the Registered Manager told us that due to personal reasons they had not been in the home as much as they would like over the past year. The Registered Manager recognised that this meant that the paperwork was not up to standard. They believed that the hands-on care of people living at the home had not suffered and they invited us to observe the way people were cared for. The Registered Manager knew what needed to be done in order to be able to demonstrate compliance and they informed us of their intention to ensure that the paper-work will become compliant.

The home was in need of refurbishment and the Registered Manager told us that they intended to carry out a plan of works over the next year.

We found that people were being offered choices and these were respected. Where people lacked capacity to make decisions people's rights were respected and decisions made in their best interests were being made in accordance with legislation.

We saw that each person now had a person centred plan for their care, drawn up with them and written in ways they were able to understand. One person told us about how staff had helped them write their care plan. They said 'We sat and wrote it all down. I like (Staff member's name) because she is my friend. She helped me do it'. Another person's plan had been filmed and was on DVD at their request.

We found that people's medication was being given out safely and stored correctly. The records regarding the administration of medication showed a full audit trail of medication received into the home and it's administration or disposal.

Staff were employed following a full recruitment process. People told us the staff supported them well. One said 'Staff take me out. They are kind to me.'