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Burleigh House Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 January 2021

About the service

Burleigh House is a residential care home providing personal care to 11 people aged 65 and over at the time of the inspection. The service can support up to 15 people in one adapted building.

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

People’s risks were not always suitably assessed and managed and staff did not always have access to the information they needed to manage people’s risks. Medicines were not always safely managed and audits of medicines were not effective in identifying areas for improvement.

The provider did not have suitable systems in place to ensure areas of improvement were identified and acted upon. The registered manager was reactive to feedback but could not be proactive in their approach as they did not have suitable systems in place.

There were enough staff to meet people’s needs but there were gaps in the training staff had received. Staff knew how to safeguard people from abuse.

There were measures in place to prevent the spread of infections, however improvements were needed to ensure a robust approach.

People and relatives were happy with the care received and had confidence in the registered manager.

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 (published 10 January 2020) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for two consecutive inspections.

Why we inspected

We received concerns in relation to infection prevention and control practices, risk management and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report. The provider took immediate action to mitigate the most serious risks identified.

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.

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

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and governance at this inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit to check the pro

Inspection areas

Safe

Requires improvement

Updated 28 January 2021

The service was not always safe.

Details are in our safe findings below.

Effective

Good

Updated 28 January 2021

Caring

Good

Updated 28 January 2021

Responsive

Good

Updated 28 January 2021

Well-led

Requires improvement

Updated 28 January 2021

The service was not always well-led.

Details are in our well-led findings below.