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Inspection Summary

Overall summary & rating


Updated 2 June 2016

This unannounced inspection took place on 23 & 31 March 2016.

Burrowbeck Community Care is a domiciliary care agency which provides support to adults living in Lancaster, Morecambe and surrounding areas. We were informed there were approximately 61 people receiving a service from the organisation at the time of inspection.

There was not a registered manager in place. A registered manager is a person who has 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. The registered provider had recruited a manager who had been identified as becoming the registered manager. They were on duty on both days of the inspection and told us they were in the process of starting registration. We saw evidence the registration process with the Care Quality Commission had commenced.

People spoke positively about the quality of service provision on offer. People told us staffing levels were conducive to meet their needs. However, people told us staff punctuality was sometimes a concern. We discussed this with the manager who provided evidence to show they were taking action to improve on this.

Arrangements were in place to protect people from risk of abuse. People told us they felt safe and secure. Staff had a knowledge of safeguarding procedures and were aware of their responsibilities for reporting any concerns.

Recruitment procedures were in place to ensure staff were correctly vetted before commencing employment. Staff retention was good and people said they benefited from staff who knew them well.

Suitable arrangements were in place for managing and administering medicines. People were encouraged to self-administer medicines where appropriate. Risks of self-administration were managed.

People’s healthcare needs were monitored. Care plans were in place for people who used the service. Care plans covered support needs and personal wishes. Plans were reviewed and updated at regular intervals and information was sought from appropriate professionals as and when required.

Training was provided for staff to enable them to carry out their tasks proficiently. Staff training was monitored using a training matrix. The organisation responded to the needs of people using the service and tailored training to meet their needs.

People said they were supported at appropriate times to meet their nutritional needs. Strategies were in place to promote healthy eating where appropriate.

The manager had implemented a range of assurance systems to monitor quality and effectiveness of the service provided.

Systems were in place to monitor and manage risk. Information regarding accidents and incidents was monitored so trends and themes could be identified and processes put in place to minimise risk. External consultants were commissioned to monitor and promote health and safety.

The registered provider encouraged people to live active lives within their community.

Staff were positive about ways in which the service was managed. Staff spoke highly about levels of training on offer and support from management. Staff described the working culture as positive.

Inspection areas



Updated 2 June 2016

The service was safe.

People who used the service told us they felt safe.

Processes were in place to protect people from abuse. The provider had robust recruitment procedures in place and staff were aware of their responsibilities in responding to abuse.

Suitable arrangements were in place for management of all medicines.

The registered provider ensured there were appropriate numbers of suitably qualified staff on duty to meet the needs of people who used the service.



Updated 2 June 2016

The service was effective.

People’s needs were monitored and advice was sought from other health professionals, where appropriate. People who used the service told us their nutritional and health needs were met.

Staff had access to ongoing training to meet the individual needs of people they supported.

Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and the relevance to their work.



Updated 2 June 2016

Staff were caring.

People who used the service were positive about the staff who worked for Burrowbeck Community Care.

Staff had a good understanding of each person in order to deliver person centred care. People’s preferences, likes and dislikes had been discussed so staff could deliver personalised care.

People told us staff treated people with patience, warmth and compassion and respected people’s rights to privacy, dignity and independence.



Updated 2 June 2016

The service was responsive.

Records showed people were involved in making decisions about what was important to them. People’s care needs were kept under review and staff responded quickly when people’s needs changed.

The registered provider had a complaints system in place to ensure all complaints were addressed and investigated in a timely manner.

The registered provider worked innovatively to ensure people could be included in community activities.



Updated 2 June 2016

The service was well led.

Systems had been put in place to support the staff during the absence of the lack of registered manager. A new manager had been identified and was in the process of applying to become the registered manager.

The registered provider had good working relationships with the staff team and all staff commended the skills of management.

Regular communication took place between management, staff and people who used the service as a means to improve service delivery.