We carried out a review of the data available to us about Pauline Burnet House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Pauline Burnet House, you can give feedback on this service.
We found the following examples of good practice.
Visitors to the service had their temperature taken, completed a health questionnaire and wore personal protective equipment (PPE). Visitors who were not regularly tested for COVID-19 as part of a testing programme were asked to undertake a Lateral Flow Test (LFT) before entering the building. These tests take 30 minutes to receive a result.
The home had an ample supply of PPE. All staff had received training in the correct use of PPE, and how to take it off and put it on safely.
People were supported to have regular contact with their families and friends through video and telephone calls.
Regular COVID-19 testing for all people and staff living and working in the home was regularly carried out.
Cleaning of the home, including frequently touched surfaces, had increased to reduce the risk of transmission of infection. There were ample supplies of cleaning equipment to reduce the spread of infection.
The service supported staff to travel to work safely without the need to use public transport. If necessary, the service paid for staff to access work via a taxi.
The care home has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism living in the home can live as ordinary a life as any citizen.
Pauline Burnet House is registered to accommodate up to nine people with learning disabilities, autistic spectrum disorder and/or physical disability. The home is located on the edge of the city of Cambridge. Shops and other amenities are a short walk from the home.
At our last inspection in July 2016 we rated the home ‘good’. At this inspection we found the evidence continued to support the rating of ‘good’ and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the home has not changed since our last inspection.
This inspection was completed on 5 February 2019 and there were nine people living in the home at the time of the inspection.
A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run. The registered manager understood their responsibilities in relation to notifying CQC of certain events that happened at the home.
People continued to be kept as safe as possible because staff understood their roles and responsibilities in relation to keeping people safe from harm and abuse. Potential risks to people had been recognised and information on how to minimise risks had been recorded as guidance for staff to follow. People received their prescribed medicines, which were managed safely. There were enough staff on duty with the right mix of skills to meet people’s support needs.
People continued to receive an effective service because their needs were met by staff who are well trained and supported to do their job. People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the home support this practice. People's nutritional needs were met by staff who knew each person's needs well. People’s health and wellbeing was maintained and they had access to a range of health and social care professionals.
People continued to receive good care because staff treated people with kindness, compassion, dignity and respect. People had choices in all aspects of their daily lives and could continue with interests, activities and friendships outside the home. Staff ensured people remained as independent as possible.
People continued to receive a service that was responsive. People and their relatives (where agreed) were involved in their personalised support plans and reviews. The information about them in relation to their care and support was up to date. People were encouraged to take part in a range of activities that they enjoyed and were the choice of the person at that time. This helped promote social inclusion. More information was required to support people with end of life care should this ever be needed.
People continued to receive a service that was well led. Quality assurance systems were used to check that the staff provided quality care and the manager made improvements where necessary. People were encouraged to share their views about the quality of the home provided.
Further information is in the detailed findings below.
This unannounced inspection took place on 14 July 2016.
The service had a registered manager. However, as they managed several of the provider’s services a service manager was in post and they undertook the day to day running and management of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Staff had been trained in safeguarding people from harm and they knew the procedures and actions to take should they identify any, or potential, harm.
A sufficient number of suitably qualified and competent staff were in place to support people with their care and support needs. Staff were safely recruited through a process that helped ensure that only suitable staff were employed.
People were safely supported with their prescribed medicines. Trained staff who had been deemed competent to administer medicines undertook this in a safe way. Medicines were managed and administered safely.
People were supported to be safe by staff who were skilled in identifying and managing any potential risk. People with behaviours which could challenge others were supported by staff using recognised standards of proactive de-escalation.
The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service’s registered manager and staff were knowledgeable about when an assessment of people’s mental capacity was required. Staff were aware of the circumstances and conditions when an application to lawfully deprive any person of their liberty was required. Mental capacity assessments had been completed to identify those people were needed to be lawfully deprived of their liberty.
Support staff and managers received regular supervision. This was planned to develop their skills, increase their knowledge and encourage and mentor care staff to obtain additional care related and management qualifications.
People’s care was provided with consideration of each person’s individual care needs and was undertaken with compassion by staff. People were supported to improve their independent living skills and staff respected their choices.
People used their preferred means of communication, or told staff, to inform them of their preferences and needs. Relatives, care staff, health care professionals and social workers contributed to the on-going development of people’s care needs. People’s care plans were in a format that enabled people to contribute, and be involved in, their care planning.
People were supported to access a range of health care professionals including a speech and language therapist, psychologist and GP services. Staff ensured that they adhered to the advice and guidance provided by health care professionals.
People were encouraged to buy, prepare, cook and eat sufficient quantities of a healthy and , balanced diet which was appropriate for their needs.
People were involved where and whenever this was possible in developing the service. The service manager was proactive in taking actions to prevent the occurrence of any potential incident. Staff knew when people were happy with their care.
The provider’s representative and service manager had effective audits and quality assurance in place. These audits were used as a means to drive improvements.
Pauline Burnet House is registered to provide accommodation for up to eight people who require nursing or personal care. At the time of our inspection there were eight people living at the service. Accommodation is provided on both floors of the two storey building and all bedrooms are single rooms.
At our previous inspection on 11 April 2014 the provider was meeting the regulations that we assessed. This unannounced inspection took place on 8 September 2015.
The service had a registered manager. The registered manager also managed four other locations registered by the provider. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The provider’s recruitment process was robust. This helped ensure that only those staff who were deemed suitable to work with people using the service were offered employment. There was a sufficient number of suitably qualified and experienced staff working at the service. An induction process was in place to support and develop new staff.
Staff’s competency to safely administer medicines was assessed regularly to ensure they adhered to safe practice. This was after staff had successfully completed medicines administration training. However, not all medicines were recorded accurately or stored as safely as they should have been. This was in contravention of the provider’s policy and put people at risk of unsafe medicines administration.
Staff had been trained in protecting people from harm. They were knowledgeable about reporting suspected or actual harm and had a good understanding of what protecting people from harm meant.
The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service’s manager and staff were knowledgeable about assessing people’s ability to make specific decisions about their care needs. Staff were aware of the circumstances and conditions when an application to lawfully deprive any person of their liberty was required.
People’s care was provided with compassion and in a dignified and private manner. People were encouraged to be as independent as practicable with their day to day living skills, choices and preferences.
People’s care records were reviewed regularly and kept up-to-date by staff. This was to help ensure that people were provided with care and support based upon the person’s latest and most up-to-date care information. People were involved in their care planning and were supported by relatives, staff and social workers. An advocacy service was available if people required, or were identified as needing, this support.
People were supported to access a range of health care professionals including speech and language therapists, GP and opticians. Advice and guidance provided to staff by health care professionals was followed and adhered. Prompt action was taken in response to the people’s changing health care needs. Risk assessments were in place to help manage each person’s assessed health risks.
People were encouraged and supported to eat a healthy balanced diet which was appropriate for their needs. People were supported to have sufficient quantities of the food and drinks that they preferred.
People, their relatives and staff were provided with information and guidance about how to raise compliments or concerns. Staff knew how to respond to any reported concerns or suggestions. Not all complaints were recorded. This limited the registered manager’s and provider’s ability to respond effectively to concerns.
The provider, registered manager and the service’s manager had audits and quality assurance processes and procedures in place. However, not all audits were effective in identifying the issues we found.
Staff were supported to develop their skills, increase their knowledge and obtain additional care related and management qualifications.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take in the full version of the report.
Is the service safe?
When we arrived at the service the staff on duty asked to see our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.
Staff training records showed that people had been suitably trained in infection control practice. We saw evidence of good health & safety practices in the kitchen through the use of colour coded chopping boards. We also saw that the service had a detailed set of policy documents and risk assessments relating to the cleanliness of the environment and infection control.
We saw evidence, in the form of a proposal to the local authority, that staffing levels had been assessed and identified on the basis of what levels of staffing were appropriate to the current needs of people who used the service.
We saw that the staff were provided with training in safeguarding vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS), which were updated every year. This meant that staff were provided with the information that they needed to ensure that people were safeguarded.
Is the service effective?
People's needs were fully assessed by staff before they moved in to the service, and this assessment was used to inform the level and type of support people received.
People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.
Is the service caring?
Observations made during the inspection showed that there were friendly, respectful and supportive relationships in place between staff and people living in the home. We observed staff assisting people in the activities of daily living with due regard for their privacy and choice.
Staff spoke with people in a kind way to respectfully preserve the person's dignity when providing care and personal assistance. We observed members of staff assisting people in a reassuring and unhurried way with choices being offered at all times such as meals and where they wished to sit.
Is the service responsive?
People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to by staff. People had access to independent advocacy services and informal forums to make a complaint if they were unhappy. We saw that where people had raised concerns appropriate action had been taken to address them. People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and district nurse.
Is the service well led?
The service worked well with other agencies and services to make sure people received their care in a joined up way. The service completed weekly audits to monitor a number of key areas which included; care issues, medication, finances and health & safety. The service also had monthly visits from the service manager to ensure that the home was delivering safe and effective care.The service had a quality assurance system and records seen by us showed that identified shortfalls had been addressed promptly. As a result the quality of the service was continuingly improving.
The majority of people that we met with during our inspection visit on 8 May 2013 were not able to tell us about the care and support they received whilst living in the home, due to their complex needs. However, observations made during our visit showed that people were satisfied and happy with the care and the attention they received from care staff; One person did tell us that 'The staff help me to go out shopping.'
Care and support was being regularly reviewed to ensure that peoples' needs were being met. There was evidence of people's involvement in the planning of their care and support.
The premises were kept clean and were generally well maintained to meet the needs of people. However, some areas of the home need refurbishment.
There were thorough recruitment procedures in place to ensure that only staff who were suitable to work with vulnerable people were employed.
The home had an effective system to effectively deal with complaints that people using the service. People regularly had access to staff to resolve any concerns that they had.
Although some people did not verbally tell us their views about living in the home, we
observed that there was a happy rapport between staff and people and that care and support was being provided sensitively by staff. The atmosphere in the home was positive, homely and social with people cheerfully engaged with staff.