Archived: Burleigh House

Updated 23 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Burleigh House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Burleigh House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. We approached Healthwatch for their feedback; Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. They did not have any feedback to share. The local authority shared their feedback about the service. We used all this information to plan our inspection.

During the inspection

We spoke with eight people who used the service and seven relatives about their experience of the care provided. We spoke with six members of staff including the registered manager, deputy manager and care workers. We also spoke with seven professionals who were involved in supporting people who used the service.

We reviewed a range of records. This included two people’s care records and reviewed multiple peoples medicine records. We looked at two staff files in relation to recruitment. We also looked at a variety of records relating to the management of the service, including quality audits, incidents and building safety records. We had a video call with the registered manager and deputy manager after our site visit in order to seek clarification and to validate evidence found. We looked at training data and policies and procedures. We spoke to the nominated individual to ask them about how they monitored the service. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 23 August 2022

About the service

Burleigh House is a residential care home providing accommodation and personal care to up to 15 people. The service provides support older people who may be living with dementia, mental health needs and/or a physical disability. At the time of our inspection there were 13 people using the service.

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

Medicines were not always managed safely as ‘when required’ medicines were not always administered in line with the prescription. There was often missing guidance for ‘when required’ medicines. Risks were not always assessed and planned for. Lessons had not always been learned when things went wrong, as action was not always taken when building safety defects had been identified. People were generally protected from cross infection, but the non-wearing of masks by some visitors (which was their own choice) had not been assessed. There were enough staff, so people were not unsafe, but further consideration was needed to ensure people had meaningful activity. Staff were overall recruited safely however further improvements were needed to ensure references were sought from most recent employers. People felt safe and were protected from the risk of abuse.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. One person on covert medicines did not have this fully assessed and reviewed.

Quality assurance systems were not always effective at identifying areas for improvement and at ensuring action was taken when concerns were noted. Building safety checks had not always been undertaken in a timely manner. The registered manager understood their duty of candour. People, relatives and staff were asked for their opinion. Relatives and professionals were positive about the registered manager and felt the service worked in partnership.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (report published 28 January 2021). At this inspection we found the provider remained in breach of regulations and remained rated requires improvement.

Why we inspected

We carried out an unannounced focused inspection of safe and well-led at this service in December 2020. Breaches of regulations were found in relation to safe care and treatment and ineffective monitoring systems. The provider was issued with warning notices for these breaches and had a deadline to be compliant by.

We undertook this focused inspection to check they had now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those breaches.

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 COVID-19 and other infection outbreaks effectively. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed and it remains requires improvement based on the findings of this inspection. We have found evidence that the provider still needed to make improvements. Please see the safe and well-led sections of this report. You can see what action we have asked the provider to take at the end 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.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and the monitoring of the quality and safety of care at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.