Burleigh House

Updated 7 April 2021

The inspection

This was a focused inspection to check on information of concern we had received about the service.

Inspection team

This inspection was undertaken by one inspector.

Service and service type

Burleigh House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager who was registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave five minutes notice so we could ensure that measures were in place to support an inspection and manage any infection control risks. The provider was not aware of our inspection prior to our visit on 25 November 2020.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We did not request a provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection. We had requested information from the provider prior to the inspection and this information was used as part of the inspection plan.

During the inspection

We spoke with five members of staff including the registered manager. We spoke with four people who used the service and received feedback from five relatives. We contacted the local authority for their feedback.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection

We continued to seek clarification from the provider to validate evidence found and reviewed information the registered manager had developed to help address the issues identified by us. We spoke with the provider and the registered manager who gave us assurances about action already taken and further actions planned to address the shortfalls.

Updated 7 April 2021

About the service

Burleigh House is a care home providing accommodation for up to 44 older people, some of whom are living with dementia. At the time of the inspection there were 41 people living at the home.

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

People and their relatives told us they felt safe and that staff were kind. They told us the staff team did a good job. Staff told us people were well cared for and they would be happy for their relatives to live at Burleigh House. Visiting professionals also gave positive feedback about the home.

Staff spoke with people nicely and gave them choices about their day. However, on the day of the inspection, some people were not always dressed appropriately for the weather, such as not wearing socks or appropriate footwear or clothing such as short sleeves. It was not clear if this was people’s choice or an oversight. Visiting professionals told us they had never had concerns about people’s welfare in the home. While staff knew people well, care plans needed further development to ensure they were personalised and included all care needs.

Medicines were managed safely in the most part. Supervisions were carried out with staff if an error occurred and audits needed to check that plans for medicines prescribed as needed were in place.

Staff knew how to recognise and report abuse. However, unexplained injuries, such as bruises or skin tears, that were either observed on the inspection or recorded on people’s body maps, were not always logged on the registered manager’s incidents and accident overview. As a result, they were not aware of all injuries and they had not been investigated. Following the inspection, the provider submitted information stating that one injury was a scratch and they had not considered this to require recording. They also stated that they were not able to see injuries on another person’s arm as reported by us. We were also advised that when some injuries had occurred, they liaised with the visiting nurse or GP who did not raise concerns. However, there was a lack of oversight and monitoring of these injuries to help identify themes or trends and to ensure all appropriate actions had been taken.

Training relating to infection control and COVID-19 had been delivered. Staff felt confident in their knowledge. However, we did note that the chef did not wear a mask in the kitchen. There were processes in place to help keep people safe from being at risk of COVID-19 and there had been no cases in the home.

Staff training, supervision and support was given, and staff felt they could go to the registered manager if they had any concerns. There was a robust recruitment process in place to help ensure staff employed were suitable to work in a care setting.

Since the last inspection, a new registered manager had been in post since February 2020. There were quality assurance systems in place, however these needed to be further developed to ensure they were robust. The provider and the registered manager were committed to make the required improvements and started implementing new systems following the inspection.

Rating at last inspection

The last rating for this service was Good (published 10 October 2017).

Why we inspected

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about people’s safety and welfare. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with safety and welfare of people, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

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. Please see the safe section 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.

Follow up

We will work alongside the provider and 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.