Burnham Lodge

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety. Safety events were reported and investigated. Lessons were learnt to continually identify and embed good practice.

Staff knew how to access the provider’s policy which was up to date. Staff demonstrated a good knowledge of how to report safety events, and knew what course of action to take, for example, in the event of a fall. We saw staff had reported safety events when required. Records showed that accidents, incidents and falls were analysed each month with root causes, themes and trends identified. Lessons learned as a result were communicated in staff handovers and staff meetings.

Staff told us they received debriefs from the management team after events occurred, which provided an “opportunity to reflect on what happened, understand if there are any contributing factors, and discuss how similar incidents can be prevented in the future.”

The services safety events log showed a reduction in the number of accidents, incidents and falls that had occurred over the last year. People told us, “Nothing’s even happened” and, “I just feel safe.”

This meant there were systems in place to recognise where people could be protected from the risk of future harm, and the service could ensure their safety.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service worked exceptionally well with professional partners to ensure safe, continuous care for people to move into the home from other healthcare services. These moves were structured over a period of time to allow people to safely adjust their new environment. People and relatives told us they felt staff were well trained in meeting people’s diverse needs when moving into the home. The service had arranged further specific training with healthcare services to support people’s diverse needs.

People, their relatives, staff and professionals were involved in building care plans and risk assessments, to ensure the person was at the heart of their care when accessing different services. People’s relatives told us, “We were involved in agreeing the care plan at the start and all our questions have been answered”, and “They made us very welcome, reassuring [person] who didn’t want to be here. They made the transition very easy.”

However, not all initial assessments were thorough, and care plans did not always detail how people’s medical conditions impacted their day-to-day lives. We gave feedback to the provider, and they took action to rectify this.

We observed staff responding to an emergency admission on the day in a calm manner. We observed risk assessments and care plans put into place before the person had arrived, staff told us, “We will review them once the person is here and we know more about them.”

The service held hospital packs for people if they needed to access healthcare services, including personal details, current care records, and observations. The service planned for people to be accompanied to appointments if they did not have a loved one to attend with them. A person’s relative told us, “A doctor sees [person] regularly and they sent someone with [person] to the dental surgery when I wasn’t available.”

This meant that people experienced safe, continuous care that met their needs when transitioning between different services, including the home.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service held a comprehensive log of safeguarding concerns that had been reported to external agencies where necessary. Staff received regular training and had a good understanding of what to do to make sure people were protected from harm or abuse. Records evidenced safeguarding incidents were investigated and lessons learned were shared with the team, ensuring that continuous improvements in process and procedure protected people from the risk of harm.

The service had detailed safeguarding strategies to support a person who was at risk of leaving the home, to protect them from the risk of harm.

Records evidenced if people had Deprivation of Liberty Safeguards (DoLS) in place, the service applied and updated them where necessary. Staff demonstrated a good knowledge of how people with DoLS should be protected and identified any restrictive practises.

We observed people leaving the building with support if they wished. This meant people were enabled and supported to understand the risk of harm.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had assessments in place where it was identified they may be at risk from events such as falls, behaviour that communicates an emotion or distress, and choking.

Positive behaviour support plans were in place with clear de-escalation techniques for staff to use to mitigate the risk of distressed behaviour, including the use of verbal and non-verbal techniques for people who had sensory impairments. A staff member told us, “I carefully observe for triggers, such as environmental changes, pain, or unmet emotional needs, and adjust my approach accordingly. I always follow the individual care plan, stay calm, speak in a reassuring tone, and give the person space if needed. I also ensure incidents are accurately recorded and reported, allowing the team to review strategies and adapt care plans to prevent future challenges.”

We observed staff responding to people’s distress safely, in a way that protected them from risks of harm. This meant that people and staff were protected from the potential impact of distressed behaviour.

Staff supported people to mitigate the risk of falls, by ensuring people used assistive equipment to mobilise and move around when required. A person told us, “The [staff] are good for when I’m walking, as if I fall, I feel safe that they can hold me.” A person’s relative told us, “[they have] a few mobility issues, but staff are always there for [them] and I’m 100% sure [they’re] safe there.” This meant that people were actively involved in understanding and managing their own safety.

Records and observations evidenced where people had capacity but required a modified diet to protect them from the risk of choking. Staff discussed the risks with them associated with eating food that hadn’t been appropriately modified. All staff knew who required modified diets, and we observed staff acting appropriately to ensure people received their meals at the required consistency, sometimes incorporating modified food into a wider dish in a discreet way. This approach meant that people were supported to take positive risks while still maintaining their safety.

Staff demonstrated a good understanding of how to support people to eat and drink safely and reduce the risk of choking. However, people’s records did not always provide clear guidance on how to manage choking risks or what actions staff should take if an incident occurred. Although staff documented whether individuals received meals modified to their assessed dietary needs, we found inconsistencies in how food textures were recorded in one person’s daily notes. As a result, staff did not always have reliable written information to help them manage choking risks, and it was not always evident that people consistently received the correct modified meals. However, we did not identify any safety incidents relating to choking.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean, tidy, and free from hazards or malodours. Relatives told us, “It never smells”, and “there’s a relaxed vibe to the place.” Environmental risks were assessed, addressed, and health and safety audits were carried out regularly. A maintenance team based at the site were observed to be working safely on the day with people and staff in the home.

The staff team knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment people needed. We observed staff organising refresher training on the day of our visit for staff to use equipment to reduce a person’s discomfort during personal care. The service worked with external professionals to review people’s assistive equipment and aids, enabling the delivery of safe care.

The service had a refurbishment plan in place to improve the environment to become more “dementia friendly”, including the installation of sensory spaces, and textured surfaces and walls, for those with sensory impairments.

Staff were involved in regular fire safety checks, including fire drills. Staff were able to demonstrate to us that they would do in the event of a fire, ensuring people were protected during the risk of emergency evacuations. Records evidenced who the designated fire marshal was on each shift, with this information clearly displayed in communal areas. An in-date emergency evacuation procedure was in place, and planned for multiple eventualities including fires, electrical failure, water failure or lock down procedures.

Personal Emergency Evacuation Plans were in place for people, however, did not always detail people’s location within the home, or steps for staff to take if the person could not be evacuated (such as remaining in their room behind fire-resistant doors). We gave feedback to the provider, and they took action to remedy this.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff received training in various areas to ensure they understood people’s needs. The provider worked with partners to deliver clinical training around catheterisation, stoma care, PEG feeding, tissue viability, and medication administration. Records evidenced that not all staff were fully compliant with all their training, however, this was actively monitored by the provider. Records evidenced that staff received supervision and appraisals on a regular basis and attended staff meetings.

Care was delivered by a stable staffing team, management, and a consistent agency team where needed. Staff told us, “[The] agency do a really good job in supporting us.” We spoke with agency staff on the day and saw that they knew people well. An agency worker told us, “I always read [the person’s] care plan and risk assessments before I start work.” This meant that people experienced continuity of care from familiar staff, who understood their roles and responsibilities.

We observed staffing levels in the home adequately met people’s needs. The service used a dependency tool, to ensure there was enough staff deployed. This was clearly displayed in the home, along with staff responsibilities on each shift.

People provided mixed feedback about staffing levels. People told us, “There have been moments of crisis, like in the mornings, there’s not enough staff to get me up”, and “I think some days they have to fight to get the staff.” People also told us, “I’ve never seen them short staffed. I think there’s quite a lot as they’ve all got different colours on”, and “There’s enough any time and at night you can get someone if you need to.”

Relatives told us, “There seem plenty [of staff], [the person has] only been here for a month”, and “They’ve obviously got busy times so it seems short staffed, like at lunch times when [person] needs [their] medication and a drink.”

People provided mixed feedback, including “That [call bell], I pressed for nearly an hour before someone came as [person next door] wasn’t well”, and “I can’t always get attention when I press the button for things like the toilet or something like that. It’s not any particular time.” People also told us, “[they are] not short staffed”, and “Oh yes, if I push my little buzzer, they get me a cup of tea and get me whatever I need.”

A relative told us they felt people were left in communal areas for some time with little engagement outside of activity times, care times or mealtimes. We observed this on our first visit to the site; however, we did not observe anyone waiting for specific support with care needs. We shared feedback with the provider, and they acted to remedy this.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff demonstrated a clear knowledge of infection prevention control. The Infection Prevention and Control (IPC) lead carried out regular auditing and provided evidence of compliance or non-compliance with IPC standards. Audits did not always explicitly state corrective actions, however, staff meeting minutes evidenced that audit findings and lessons learned were discussed.

Cleaning records were comprehensive, with no recorded gaps. There had been no outbreaks of illness in the home. We observed staff donning Personal Protective Equipment (PPE) appropriately and dispose of it when required.

At lunchtime, staff used cloth aprons to provide a more homely environment while people were eating, and these were washed appropriately. We observed fridges and the kitchen to be clean, with safe food hygiene practises followed. The service had recently received a 5-star rating in their food safety inspection.

We asked people if staff wore PPE. Responses included, “All the time, they have their rubber gloves on”, “They certainly wear aprons and gloves if they’re doing anything for you”, and “They always have gloves on and sometimes masks. I can’t fault them.” Relatives told us “It’s very clean and tidy. They seem to be doing everything they can to prevent any infections.”

This meant people were protected from the risk of harm caused by the spread of infections.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People who were prescribed PRN (as required) medicines for health conditions such as constipation, pain, and anxiety, did not always have protocols in place. Where protocols were in place, they were not always person-centred.

People did not always have care plans for specific medications they took. For example, there was no information in a care plan or a PRN protocol for one person who was prescribed an antibiotic to prevent UTIs. For another person, this was related to their medicine for anxiety. This meant staff may not be able to administer these medicines consistently.

Medicines were stored securely and at appropriate temperatures. Improvements had been made in relation to the ordering of medicines since the last inspection. This meant there was an adequate stock of prescribed medicines. Some people were prescribed medicines to help with their mental health. The staff monitored their administration. Healthcare professionals reviewed these medicines regularly.

Records showed that people were having their medicines administered as prescribed. An electronic medicines administration (eMAR) system and care plan system were in use. Staff worked with the local GP practice and the local healthcare agencies, such as the older adult community mental health team to optimise medicines for people living at the home. Medicine reviews were often remotely carried out by the clinical pharmacist from the GP practice.

There was a medicine policy and process in place to report and investigate medicine errors and incidents. Staff carried out medicine management audits to identify gaps and make improvements. There was a process in place to receive and act on medicine alerts.

Staff received training and were competency assessed to handle medicines safely. People’s relatives confirmed they had not experienced any problems with their loved one’s medications. People told us they knew what medicines they took and the reason why, comments included, “I know I have something for a stroke I had years and years ago and I also have another tablet…[staff name] pushes the trolley around and [staff name] can tell me what I have”, and “I’m on quite a few, pain relief, they do it for me and bring a number of [medicines] ready.”