Burger Court

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

At our last inspection we rated this key question requires improvement. At this assessment the rating remains unchanged, and we identified breaches of the legal regulation in relation to safe care and treatment. We found aspects of the service were not always safe. Risks to people's health and welfare were not always assessed and managed safely or consistently. People’s records also contained inaccurate information, both of which placed people at risk of harm or injury. Medicines were not always managed safely. People were protected from the risk of abuse, but inconsistencies in people’s records meant risks to people’s safety could be compromised. We received mixed feedback from people about how the service responded to their concerns, but there had been a notable improvement since the new manager joined the service. There were sufficient staff available to meet people’s needs, who had been recruited safely. The environment was safe and homely, but required deep cleaning in some areas.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they had not always felt listened to and there was delay in action being taken when people raised concerns. For example, 1 person told us, “I have expressed my views on occasions, but this sometimes takes time for it to filter through before seeing any changes.” However, people felt there had been an improvement in how they were listened and responded to since the appointment of the new manager. They told us they could speak to them at any time and felt listened to by them.

Staff told us they were debriefed following incidents to look at how the risk of the incident being repeated could be lessened. However, this was not evidenced in people's records.

Systems were in place for learning from incidents in the home, but there was a lack of evidence to show these systems were always followed. For example, incident forms were filled out, which included details of what had happened and there was a section for lessons learned, but this was not consistently completed.

People told us they received support and information in advance of when they moved into the service. Comments from people included, “I feel I was given good information when moving into this home, they gave me all the information I needed” and “The process was very good when moving into this home it was a smooth process.” People also felt supported to access healthcare appointments and spoke positively of the support they received. For example, 1 person told us, “[Staff] make appointments on your behalf and attend the appointments with you. We travel by bus to get to the appointments.”

The manager gave examples of how people were supported to transition between services including admission to, and discharge from, the service. Staff worked with the person, other care providers and involved health and social care professionals to make sure people received the support they needed to prepare for their transition. Staff also supported people to visit new services, with a view to moving on from the home. Staff told us care plans and risk assessments helped them identify where a person’s condition may be deteriorating. Staff said they would raise this with senior staff to make sure people received the right support.

We did not receive feedback from partners regarding this specific quality statement.

Processes were in place to make sure staff supported people, and shared information, to make any transition between services, including admission to hospital, as efficient as possible. However, we found the 3 most recent admissions to the service had not followed the admissions policy and did not have a pre-admission assessment in place. This meant we could not be assured the service had carried out a full assessment prior to admission to ensure they could meet the person’s individual needs.

People and their relatives told us they generally felt safe, but this this was compromised at times by the behaviours of other people living at the home. Comments included, “Most of the time I do feel safe, but there are times when I felt unsafe because some of the residents can be aggressive towards other residents and staff” and “I feel safe staying within the home, the staff support me well and keep me safe.” The provider was working closely with relevant agencies to ensure this situation was addressed and appropriate support was in place.

The manager maintained a good overview of all safeguarding referrals, which were made appropriately, and the outcomes. The manager told us they had a good relationship with the safeguarding team and could discuss issues with them as needed. Staff told us they received training in safeguarding, which explained the types of abuse and neglect to be aware of. They knew when and how to report safeguarding concerns, either internally or to the local authority if necessary.

We observed people avoid 1 person living at the home, who they felt could compromise their safety. However, we saw staff were always present with this person. We also saw information displayed in communal areas relating to safeguarding, raising concerns and complaints.

Systems and processes were in place to protect people from the risk of abuse and harm, although some inconsistencies in people’s care plans and risk assessments meant risks to people’s safety could be compromised.

We found there was evidence of people being involved in the development of their risk assessments and reviews of their records. However, actions taken as a result of people’s input were not always evident. For example, 1 person’s risk assessments clearly demonstrated they had been involved in their development and review. However, although it had been recorded during the review that that the person had asked for some elements of the risk assessments to be removed, this had not been done.

We found people’s risk assessments needed reviewing and updating, which the manager was already aware of. They had started the process prior to our assessment and recognised this was priority work. However, progress was slow, and the manager needed support to make sure people’s risk assessments were current and accurate. We raised this with the provider, who agreed to ensure additional support was in place to update people’s records in a timely manner.

During the visits we carried out to the service, we observed staff were present, available and responsive to people in communal areas.

Risks to people's health and welfare were not always assessed and managed safely or consistently. Records also contained inaccurate information, both of which placed people at risk of harm or injury. We reviewed the care records of 1 person, who had multiple health conditions, and found they did not contain any associated assessments, or guidance for staff on how to support this person to manage these conditions safely. Another person’s care records also referred to a health condition, which had not been adequately assessed. We were later told that the records for this person were not accurate, as this person did not actually have this health condition. This meant staff did not have accurate information about how to support this person safely. We also found people’s records were not always routinely updated following incidents involving their safety. This meant we could not be assured all measures were taken to reduce the likelihood of these incidents recurring, or that the least restrictive intervention had been considered.

People did not raise any issues about the safety of the physical environment, but they told us they were concerned about being in the same place as a person who displayed threatening behaviour. Staff were in constant attendance with this person whilst steps were taken to find them a more appropriate environment to meet their needs.

Staff told us the service was safe for the most part. For example, people had keys to their own rooms, and communal bathrooms and toilets could be locked. People with capacity were also able to enter and leave the building as they wished, but keypads were in place to maintain safety.

During our assessment of the service we completed a tour of the building with the home manager. The environment looked homely in the communal spaces. However, it was in need of more effective cleaning. We also identified concerns with a winding staircase which ran from the ground floor to the second floor. We found that although bannisters were in place, there was a gap in the centre which could pose a risk to people’s safety.

We found the provider had safe and effective processes in place, to routinely monitor and maintain the safety of the premises and equipment in the service. Relevant safety certificates were in place to demonstrate this. The service employed a maintenance person who had a robust schedule of safety checks. A service improvement plan was also in place which identified planned environmental improvements. We were assured environmental risks were identified, assessed and addressed by the provider. However, a timelier intervention in relation to the safety of the staircase was needed. For example, there was a risk assessment in place for the staircase and plans were in place for fitting of Perspex sheets to make sure people could not go over the bannisters, but this was yet to be implemented.

People felt there were enough staff available to meet their needs, but they also told us there had been some unsettled times due to staff leaving and new staff being introduced. They also raised concerns in relation to a language barrier with some newly recruited overseas staff. However, people told us they had confidence the manager was addressing these issues. For example, 1 person told us, “The manager is aware of these issues and is doing their best to address the problems that have arisen.”

Staff told us they thought staffing levels were sufficient to be able to provide people with the care and support they needed. They told us agency staff were sometimes used but wherever possible it was the same agency staff, to provide some continuity. We identified concerns with a lack of staff to support with cleaning the environment and supporting the manager with administrative tasks. We raised this with the provider and leaders told us in response that they were introducing cleaning and administration hours, to enable the manager and support staff to dedicate their time to their roles.

We found there were sufficient staff available to meet people’s needs. However, on our first visit to the service, we saw cleanliness of the environment was affected by a lack of cleaning staff. We raised this with the provider, who took action to address this during the assessment.

Staffing was arranged in accordance with the outcome of a tool that was used to measure people’s dependency levels. Staff told us they received training that was useful and were able to request more if they needed it. Records also showed that all required training modules and individual staff training records were above the provider’s compliance rate. Although staff were recruited safely, some of those who were newly recruited to the service told us their induction had been poor. This was due to a lack of management oversight, and whilst they had learned what they needed to know, staff told us this had come from other staff rather than through a structured process. The new manager was aware of this and had taken action to address this.

People felt the arrangements for cleaning the service needed to be reviewed to make sure their home was clean. For example, 1 person told us, “I feel the place needs updating and deep cleaning, as this is superficial. They do have an excellent maintenance man, who has kept this home running for the residents and staff when needed.”

Staff told us infection prevention and control (IPC) was one of the mandatory training modules they were required to complete. A member of staff was identified as the IPC champion for the service. However, this person had not received any training for the role. The Nominated Individual told us they were arranging for an IPC champion from another of the provider’s services to support the newly appointed IPC champion. Staff also said people were supposed to help with the cleaning because it was their home, and to develop or retain their independent living skills, however, most people were not keen to do this. They said cleaning of the service was mostly done by staff during night shifts when the service was usually quieter.

On our first visit to the service, we found some areas needed a deep clean. This was particularly noticeable in shared bathrooms and shower rooms. For example, we saw the drain in a shower room to be clogged, a shower rail was rusty, and there was black mould in the corner of the shower area. There were cobwebs in the corners of another shower room and the light pull cord was dirty. Staircase carpets and skirting boards were also visibly dirty. We raised this with the provider, who took immediate action and cleaning took place immediately.

On the first day of our assessment the standard of cleanliness in communal areas, particularly bathroom and shower rooms, was poor. We identified there were no dedicated cleaning hours and support staff were responsible for cleaning. We raised our concerns with the provider, who took immediate action to address this and introduced weekly dedicated cleaning hours. The arrangements for cleaning of people’s rooms required review, as the service was using a supported living model of people being routinely involved in the cleaning of their rooms. As this service is a care home, people being involved in the cleaning of their rooms needed to be agreed through care planning, where appropriate.

Care plans lacked up to date, accurate information about how to support people with their medicines. We saw 1 person was supported to self-administer their medicines. A risk assessment had been completed. However, this lacked information to enable this to be done safely. People were supported to access medical appointments and appropriate monitoring relating to their medicines. However, people’s records did not always record what medicines they were prescribed and the support required.

Managers told us that staff had completed medicines training and had been assessed to ensure that they gave medicines safely. We were shown evidence of training records to confirm this. Medicines audits were completed each month. However, these were not always effective in identifying medicines-related issues occurring within the service. Staff had dedicated time to manage medicines processes, such as ordering and receiving.

Medicines support was not always recorded accurately and we found that on 2 occasions, records were not completed at the time of administration. People’s individual medicines needs were not always recorded. For example, people with diabetes and people who were on high risk medicines that required regular monitoring. Information to support staff to safely give ‘when required’ medicines was not always in place. There was a risk that people might not have got medicines when they needed them.