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Burleigh House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 January 2020

About the service

Burleigh House is a residential care home providing personal and nursing care to 12 people aged 65 and over at the time of the inspection. The service can accommodate up to 15 people in one adapted building.

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

Improvements were needed to ensure there were effective governance systems at the service and the provider had a clear oversight. Feedback sought from people had not always been acted on to make changes to the service. People were at risk of infection and harm because risks associated with the environment had not been mitigated. Improvements were needed to the way staff were deployed to ensure people received direct care and domestic tasks were completed as required.

People were protected from abuse because staff and the registered manager understood their responsibilities to protect people. Medicines were managed safely. The provider used safe recruitment practices and people’s individual risks were assessed and managed. Learning was taken from incidents and accidents to lower the risk of further occurrences.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported with their nutritional needs, and advice was sought from healthcare professionals to maintain people’s health and wellbeing.

People were supported by caring staff that supported people with patience. People’s choices were respected in line with their individual communication needs to promote informed decision making. People’s right to privacy was up held and their independence was promoted.

People had the opportunity to be involved in interests and hobbies. People understood how to make a complaint and there was a system in place to investigate and respond to complaints received. People’s end of life wishes had been gained to ensure their preferences were respected at this time of their lives.

People, relatives and staff found the registered manager was approachable and supportive. The registered manager worked with other professionals to ensure people’s needs were met.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 25 May 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to risks associated with the environment and governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor the provider’s progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 10 January 2020

The service was not always safe.

Details are in our safe findings below.



Updated 10 January 2020

The service was effective.

Details are in our effective findings below.



Updated 10 January 2020

The service was caring.

Details are in our caring findings below.



Updated 10 January 2020

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 10 January 2020

The service was not always well-led.

Details are in our well-Led findings below.