Burgess Care

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 good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to premises and equipment.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety. They did not always listen to concerns about safety and did not always investigate or fully report safety events. Lessons were not consistently learnt to continually identify and embed good practice.

Staff told us there were missed opportunities to share learning, because of a culture where staff teams did not always work together to provide safe care. We found some practices which had potential to negatively impact on people’s health or safety had become accepted without challenge. For example, if people were expressing anxiety by shouting, a senior staff member told us, “Shouting would need to go over half an hour” for this to be recorded as an incident to be reviewed.

However, some staff told us they reported and recorded accidents and incidents which were then reviewed by senior staff. Staff told us changes in people’s support needs because of an incident were shared with them. One staff member explained, “We get informed through the team, or they write it on the board (in the office) or they put it in the communication book."

Systems used by the provider to detect patterns of incidents were not working well. There were limited opportunities for staff working with people to check for patterns which may indicate care needed to be changed for people. Debriefs were not always held with people and staff after incidents. There were delays in fully recording incidents. This increased the risk of repetition of incidents and did not reflect a culture of curiosity and learning to improve people’s experiences and outcomes. Furthermore, the provider’s failure to undertaken effective and prompt reviews of incidents meant people were exposed to unnecessary risk.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Some relatives told us they were not informed about health appointments which were planned for their family members, so were not able to attend with them. They also advised us there had been delays in collecting items such as equipment their family members required and missed health appointments.

A health and social care professional told us there had been occasions where their advice had not been followed, and instances where health interventions had to be rebooked. This meant there were delays in people’s needs being met.

Many of the staff providing care for people did not have English as their first language. The provider had not promptly put support mechanisms in place to ensure staff had the best possible opportunity to develop the skills they needed to communicate effectively with people, relatives and other healthcare professionals. The failure to provide this level of support increased risks to people where accurate information needed to be quickly communicated about people’s needs, for example in emergency situations.

Staff did accompany people to health appointments, and relatives said this sometimes worked well. However, relatives told us they were not always promptly informed of the outcomes, and their family member’s attendance at appointments was dependant on the staff member who accompanied them.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly.

There were mixed views from relatives regarding their family member’s safety. One relative told us, “I am concerned for all [people] and how they were neglected. I said to staff, ‘No one cares on this site.’”Another relative said, “[Person’s name] safety there is not really an issue.”

Staff practice meant there were some instances where people’s well-being needs were not recognised, and people were at heightened risk of neglect. Staff had received training in safeguarding but did not always put their safeguarding training into practice. For example, staff did not always identify and take action to support people experiencing distress. People were also at increased risk of neglect because their health needs were not consistently monitored. However, there were other instances where staff recognised and took appropriate action when they observed poor staff practices or abuse.

Staff had not been supported to understand how to report and fully record safeguarding incidents to enable leaders to have a comprehensive overview of people’s safety. Missed opportunities through learning and reporting instance of abusive practice, exposed people to unnecessary risk.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Staff and management worked within the principles of the Mental Capacity Act 2005 (MCA). Deprivation of Liberty Safeguards (DoLS) authorisations were appropriately applied for and overseen.

Some restrictions, such as locked cupboards, were in place. Staff were not always able to explain why these were appropriate. We discussed this with senior staff, who told us they would work with staff to improve their understanding of what having a DoLS in place meant for people.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were mixed views from relatives regarding their opportunities to be involved in decisions about managing risks associated with their family member’s care. One relative told us staff had not recognised their family member needed more support. Other relatives described communication about changes in their family member’s risks as being dependant on which staff were supporting their family members.

The provider had not always given staff the guidance they needed to ensure risks to people were managed effectively. For example, some people could demonstrate responses to situations which put them or others at risk of harm. Three people’s care plans guided staff to use restrictive interventions in certain situations to maintain people’s safety. Managers and senior staff confirmed this was not accurate and diversion, distraction and guidance techniques were the highest level of interventions required to de-escalate and maintain safety.

In addition, 1 person was at risk of choking when eating and drinking. Their care plan lacked clarity around how their meals should be safely prepared and their drinks thickened to minimise the risks. Staff described this person as having intolerances to some foods. This was not reflected in the person’s nutritional care plan. Further, 1 person was suffering a decline in their health at the time of our inspection, which had impacted on their mobility. Whilst we were assured appropriate action had been taken to refer the person to external healthcare professionals, the person’s mobility support plan had not been reviewed to reflect this escalation in risk.

Where guidelines had been put in place, staff did not always display understanding of them, or how to mitigate identified risks. For example, staff knew 1 person had soya milk and associated products in their diet but did not understand this was because the person had a dairy intolerance. This lack of understanding increases risks to people, for example, if they are supported to have refreshments away from the home.

Where risks to people were known, these were not always effectively monitored. For example, where people lived with underlying health needs, records did not always evidence staff had considered and escalated concerns promptly to ensure people’s safety.

During our inspection visit, 1 person demonstrated heightened levels of anxiety and distress. We checked the person’s daily records with staff. Their records did not reflect the periods of agitation and anxiety we had observed. This meant the person’s responses had been seen as ‘normal behaviour’. Changes in the person’s presentation, emotional state or distress which may indicate a deterioration in their health or wellbeing were not being recognised and acted upon by staff.

There was an inconsistent approach to engaging with people to promote their wellbeing. Some staff spent time chatting to people and reassuring them. Other staff did not engage with people. During the inspection, a relative raised a concern their family member was being supported by a staff member who was asleep. We advised the interim manager about this and they took appropriate action.

Another relative told us, “[Staff] don’t really take them out like they used to take them out. [People] used to go shopping, swimming, they used to go to a disco, but they don’t do any that anymore.” This had potential to impact on people’s well-being. Records showed us some people had limited access to do things they may enjoy in the community.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Relatives told us concerns in relation to the safety and suitability of the building had increased and managers had not always been accessible to resolve these promptly. One relative said, “It’s shocking. They’ve been saying they’re going to get air conditioning for ages, it’s horrific for [person’s name] and the staff. I don’t feel they take it very seriously. [Person’s accommodation] at the moment looks like somebody who’s homeless lives there.” Another relative told us, “There’s been no work done on the property for god knows how long. All in all, we are not happy.”

People experienced additional risks to their safety because improvements required to the premises and equipment were not always promptly undertaken. Some areas of the home were not maintained to a satisfactory standard, such as worn and damaged woodwork, broken furniture and damage to the fabric of the building.

Fire safety was not well managed as we identified issues in the environment which impacted on people’s safety in the event of a fire. There were holes in the ceiling in an office, owing to a water leak. This created a significant risk, as fire or smoke could quickly spread along the void in the open roof space. The provider’s most recent fire risk assessment did not acknowledge or mitigate damage seen to the ceiling and did not reflect damage arising to one area of the building following impact from a car. Staff did not always understand or have access to people’s personal emergency evacuation plans. These contain essential information to support safe evacuation from the home in the event of an emergency.

Delays in completing repairs to the premises and equipment were evidenced through staff discussion and records. For example, staff told us washing machines were not repaired promptly.

Burgess Care was accessed via a security gate which was not closing or working properly at the time of our inspection. There was a significant gap between the gate panel and the post which presented a risk of people entering or leaving the site unaccompanied or unobserved. Other equipment, such as a wheelchair which was in use, was not fit for purpose, with damage to an arm rest and the foot plate missing.

Significant building work was being undertaken in 1 area of the home. Staff were not aware if risk assessments had been put in place to guide them to manage people’s safety. We saw people had access to external contractor’s equipment including a handsaw and tins of paint, increasing people’s risk of harm or ingestion.

Owing to emergency repairs required, people did not have access to permanent toilet or bathing facilities in one area of the home. A portable toilet had been installed in the car park which was accessed via steps. Staff were unaware if risk assessments had been put in place for them to follow to help reduce risks for people using the temporary portable toilet facilities. On the first day of our inspection, there was a strong odour within the portable toilet, making it unpleasant to use and presenting a potential infection control risk. By the end of the inspection, 1 bathroom had been made good in the area of the home affected.

We saw 1 broken and 1 detached window restrictor in the service. Staff we asked could not provide us with risk assessments in relation to these. Window restrictors reduce the risk of people falling from height. Poor safety practice in relation to window restrictors had gone unchallenged.

Chemicals used for cleaning were not always handled safely and in line with Control of Substances Hazardous to Health (COSHH) guidance. Cleaning products were accessible in 1 communal area of the home. Correct storage of hazardous substances under COSHH is vital to prevent harm to people, for example, if ingested. It is also important to ensure staff and visitor safety, to avoid dangerous chemical reactions, and contain accidental spills.

Staff stored their own personal belongings and bags in a communal lounge, despite staff lockers being available to them. No consideration had been given to people having access to staff bags and property that could contain items which had potential to cause them harm.

On the first day of the inspection, we saw excessive storage of unused equipment, broken furniture and uneven surfaces in the communal garden. These issues presented a hazardous environment with potential to cause injury. We saw people used the garden regularly throughout our inspection visit. The provider began to address some elements of improvements during the inspection.

The provider had a schedule of work in place to address some of the concerns we identified at this inspection, however, the commencement date of premises improvements had not been confirmed by the end of the inspection.

The provider made sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Relatives had mixed views on the staffing levels and staff skills at the home. Some said staff who had worked with their family members for extended periods of time knew them well. However, other relatives raised concerns about the knowledge and approach of staff. Both relatives and staff raised concerns about the communication skills of some staff, and we found the provider did not provide mandatory training to ensure staff had the communication skills required to care for people.

Some staff told us they had raised concerns with senior staff about staff refusing to do elements of their role which had not been addressed.

We found there were sufficient staff to care for people, but they required more support and direction to provide consistently safe care. For example, some staff had not had access to regular supervision, and meetings with senior staff had not been regularly conducted. The interim manager acknowledged staff needed further guidance and support to consolidate their learning and how it was implemented into daily practice.

Systems were in place to help to ensure staff were suitable to work with vulnerable adults.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading promptly.

The lack of effective maintenance of the premises increased the risk of the spread of infection and some areas of the service were unhygienic and unclean. Walls, furniture, floors and doors in people’s bedrooms, communal areas, corridors, shower rooms and toilets were marked, stained or soiled.

Improvements were needed to ensure safe food hygiene practices were followed. Kitchen cupboards were dirty and in 1 example, we observed a large build-up of mould which could contribute to poor health in people with weaker immune systems. We observed debris between cupboards and kitchen appliances and cobwebs in 1 kitchen reflected inadequate cleaning of the area.

We had received information of concern about a fly infestation within the service. We found whilst fly screens were in place, these were very dirty and the lack of staff oversight meant these were not always pulled down to prevent flies entering the kitchen and contaminating food. Electrical insect control systems were being installed at the time of our visit.

Staff did not always follow good infection control practices. In 1 person’s bathroom we saw staff had left a mop in a bucket with water which can quickly turn into a breeding ground for bacteria. In another person’s bathroom we saw their toothbrush was dirty and worn with splayed bristles. Splayed-out bristles can cause micro-cuts in gums which can make people prone to oral infections and gum disease.

Clinical waste was not consistently disposed of appropriately as bins did not always have a clinical waste liner. Other bins did not always have a foot operated lid mechanism and/or a lid which compromised good hand hygiene and increased the risk of cross infection to people living in the home.

An interim manager introduced “Environmental walkaround” checks during the inspection in response to the concerns we raised.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities. Staff did not always involve people in planning.

Some people were administered medicines to be given on an ‘as required’ basis. There was guidance in place to ensure people were given these medicines when they needed them. However, processes to support the administration and monitor the effectiveness of these medicines were not consistently applied. The provider’s quality assurance manager confirmed, “If someone was administered paracetamol this evening there are no monitoring forms in place. I think the houses are doing different things. They are all doing differently."

Some people were prescribed sunscreens because of their susceptibility to skin damage caused by the sun. Records showed these prescribed creams were generally only being applied by 1 member of staff. This indicated other staff were not always following the guidelines for their application.

We found some excessive quantities of some people’s prescribed creams and toothpastes. There was no evidence to show what actions had been taken to check whether this was because they had not been administered as prescribed, or whether they had been over-ordered.

Medicines were generally stored safely but we found the medicines fridge was not locked. Some prescribed toothpastes in the medicines cupboard did not have the date of opening recorded on them and their prescription labels had fallen off so it was not known whose prescribed medicines they were.

Medication audits undertaken prior to the inspection had not identified any concerns with medicines management. A further audit was undertaken by staff during the inspection. This identified several concerns which had not previously been identified.

However, only staff who had received training in safe medicines management and had their competency assessed, gave people their medicines. Medicines administration records showed people generally had been given their medicines as prescribed. We also saw some good practice when a person had to be administered their ‘as required’ medicine for anxiety because of their hay fever symptoms. Staff contacted the GP immediately and the person was able to commence a course of medicines to alleviate their hay fever symptoms the same day.