Burnside 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

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 remained requires improvement.

This meant some aspects of the service were not always safe, and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of the regulation. We also identified a further breach in regulation in relation to staffing.

However, the provider was previously in breach of the legal regulation in relation to recruitment. Improvements were found at this assessment and the provider was no longer in breach in relation to recruitment.

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.

The registered manager promoted a positive culture of openness and honesty. The provider had made improvements since the previous inspection. The registered manager reviewed incidents and accidents, including analysing falls to reduce the risk of recurrence. Where necessary, they contacted professionals for additional support and arranged specific equipment, such as low-rise beds.

Despite these improvements, further action was required to meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and to consistently identify and embed good practice.

The provider did not consistently manage or monitor people’s safety. Existing systems and processes failed to identify the concerns found during this inspection. Daily records were not reviewed to ensure people’s needs and identified risks were being met and minimised.

A contingency plan was in place and regularly reviewed but lacked sufficient guidance. For example, it did not specify what steps to take if the internet failed to ensure this failure did not impact on staff’s ability to provide safe care to people living at the service. The management team told us they were unable to implement or update care plans and risk assessments due to this failure. As a result, staff did not always have access to up-to-date and relevant guidance on people’s falls risks, placing them at risk of avoidable harm. Whilst no person had come to harm, this contributed to a breach of regulation relating to safe care and treatment.

The provider worked with people and healthcare partners. The registered manager told us they ensured continuity of care, including during transitions between services. They described how they were supporting a person to move to another service, explaining that due to improvements in the person’s ability and health, a different setting would be more beneficial. This was being done in collaboration with the person’s social worker and other adult social care services.

The provider worked with people and healthcare partners to understand what safety meant to individuals and how best to achieve it. Staff focused on improving people’s lives while protecting their rights to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were shared promptly and appropriately.

People can only be deprived of their liberty for care and treatment with the correct legal authority. In care homes, this is managed through the Deprivation of Liberty Safeguards (DoLS), part of the Mental Capacity Act 2005 (MCA). The service had applied for DoLS appropriately but did not always update and resubmit applications when changes occurred in someone’s care. This meant the service may have been restricting people’s liberty without up to date legal authorisation.

Records showed the service raised concerns with the local authority safeguarding team. Staff told us they understood the signs of abuse and felt confident reporting concerns to the registered manager. The registered manager took action in response to these concerns.

Relatives told us they felt their loved ones were safe. Comments included, “Yes, oh yes definitely,” and “Yes, they have a good sense of humour, which is similar to (Person’s name), which helps.”

The provider did not consistently work with people to understand and manage risks. Staff did not always deliver care that met people’s needs safely.

Known risks were not always assessed. For example, the registered manager told us one person was at high risk of falls, but no risk assessment was in place to mitigate or minimise this risk.

Whilst we did not identify anyone who had come to harm, this contributed to an ongoing breach of regulation relating to safe care and treatment.

Most relatives told us they were involved in care planning when their loved one first moved into the service. However, they had not been involved recently. Comments included, “I can’t say I’ve seen it recently,” and “Not really. I told (the management team) what (Person’s name) likes, etc, but was not involved more than that.” Care plans and risk assessments did not show evidence of involvement from people or their relatives.

The provider did not consistently detect or control potential risks in the care environment. An audit action plan and an external health and safety visit identified the need for asbestos testing in March 2025. However, during the inspection in August 2025, this had not yet been completed or arranged.

Environmental risk assessments, such as for heatwaves, were in place but had not been reviewed since May 2024. We raised this with the registered manager, who told us they would take action to update them.

Whilst we did not identify anyone who had come to harm. This contributed to the breach in relation to good governance.

The provider ensured equipment supported the delivery of safe care. Improvements had been made, including restricting windows to prevent falls from height and completing regular fire safety checks on fire doors, extinguishers, and escapes. Weekly fire tests were carried out, but the registered manager could not provide evidence of regular evacuation drills.

The provider did not consistently ensure there were enough staff to meet people’s needs. The registered manager told us they had begun using a tool to assess staffing requirements, but this process had not been completed or embedded.

Relatives gave mixed feedback about staffing levels. Comments included, “There seem to be enough staff,” and “I don’t think that’s enough. Sometimes you have to wait half an hour for them (staff) to help mum onto the loo.”

Whilst we did not identify anyone who had come to harm. This contributed to the breach in relation to staffing.

Improvements had been made in recruitment practices. The provider obtained references, all staff had Disclosure and Barring Service (DBS) checks, and they were no longer in breach of the regulation relating to fit and proper persons. However, further improvements were needed. The registered manager’s process had not always worked, some gaps were still found in employment histories.

The registered manager carried out regular staff supervisions covering performance, care delivery, teamwork, training, goals, and health and well-being. Records and staff confirmed this.

Staff said training was good and they had opportunities to complete NVQs. Training records showed staff had completed training in challenging behaviour, communication, falls prevention, and moving and handling.

People told us, “The staff are helpful,” and “Staff are friendly.”

The provider assessed and managed infection risks effectively. They detected and controlled the risk of spread and shared concerns with relevant agencies promptly.

Training records showed staff had completed training in COSHH (control of substances hazardous to health, coronavirus awareness, dementia awareness, diabetes, and infection prevention and control.

A staff member told us there was good communication between domestic staff. They explained they worked together weekly and used a communication book to manage tasks and prioritise room deep cleaning. We saw records confirming this.

People and relatives told us the service was clean and tidy. Comments included, “The cleaner does all my washing and ironing. (Cleaner’s name) plumps my soft toys when they clean my room,” and “The cleaner does a good job keeping my room clean.” One relative told us, “It’s very clean. They don’t have that smell here that they do in some other places.”

The provider did not consistently ensure medicines and treatment were managed safely.

Improvements had been made, including the implementation of PRN (as required) protocols. However, medication management was not always in line with the service’s policy or national guidance. For example, medicines were not consistently disposed of safely and securely in a tamper-proof container within a cupboard until collection or return to the pharmacy.

The registered manager had displayed a poster in the staff room about flammable creams, and had a risk assessment in place which identified the hazards and existing control measures to minimise the risk, however, it was out of date and required to be reviewed in May 2024.

Although the service carried out medicine audits, these did not identify the issues found during this inspection. We raised our concerns with the registered manager, who told us they would take action to address the shortfalls.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach in relation to safe care and treatment.

Relatives told us the staff kept them informed and communicated well. Comments included, “The medication is all very good. I can look at the MARs chart if I want to,” and “They (staff) do, on a regular basis discuss medicines. (Person’s name) is funny with her tablets, they refuse to take them and then they’ll come back in 5 minutes and ask again.”