We carried out a review of the data available to us about Burlington Hall Care Home 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 Burlington Hall Care Home, you can give feedback on this service.
Burlington Hall Care Home is registered to provide accommodation and personal care for up to 53 older people, including people living with dementia. At the time of inspection, 47 people were using the service.
People’s experience of using this service:
• People continued to receive safe care. Staff understood safeguarding procedures that should be followed to report abuse and incidents of concern.
• Risk within people’s lives were appropriately managed, whilst also promoting people's independence. People's medicines were safely managed.
• Staff recruitment procedures ensured that appropriate pre-employment checks were carried out. Staffing support matched the level of assessed needs within the service during our inspection.
• Training was provided to ensure staff had the skills, knowledge and support needed to perform their roles.
• Staff were well supported by the senior management team, through team and one to one supervision meetings. The staff we spoke with were all positive about the senior staff and management in place.
• People's consent was gained before any care was provided. People were supported to have maximum choice and control over their lives and staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice.
• Staff continued to treat people with kindness, dignity and respect. Care plans reflected people’s needs and how they wanted their care to be provided. People and their family were involved in reviewing their care and making any necessary changes.
• The provider had systems in place to seek people’s views about the service and raise any concerns or complaints.
• The service continued to be well managed. Areas identified for improvement were acted upon promptly and lessons were learned through positive communication.
Rating at last inspection: Good (Last report published 26 June 2017)
Why we inspected: This was a planned inspection based on the rating at the last inspection. The rating for the service remained Good overall.
Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
At the last inspection, the service was rated Good.
At this inspection we found the service remained Good.
People using the service felt safe. Staff had received training to enable them to recognise signs and symptoms of abuse and felt confident in how to report them. People had risk assessments in place to enable them to be as independent as they could be in a safe manner. Staff knew how to manage risks to promote people’s safety, and balanced these against people’s rights to take risks and remain independent. There were sufficient staff, with the correct skill mix, on duty to support people with their needs. Effective recruitment processes were in place and followed by the service. Staff were not offered employment until satisfactory checks had been completed.
Medicines were managed safely. The processes in place ensured that the administration and handling of medicines was suitable for the people who used the service.
Staff received an induction process and on-going training. They had attended a variety of training to ensure they were able to provide care based on current practice when supporting people. They were supported with regular supervisions.
People were supported to make decisions about all aspects of their life; this was underpinned by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff were knowledgeable of this guidance and correct processes were in place to protect people. Staff gained consent before supporting people. People were able to make choices about the food and drink they had, and staff gave support when required to enable people to access a balanced diet. Drinks and snacks were available throughout the day.
People were supported to access a variety of health professional when required, including opticians and doctors, to make sure they received continuing healthcare to meet their needs.
Staff provided care and support in a caring and meaningful way. They knew the people who used the service well. People were given choices about their day to day routines and about how they wanted their care to be delivered. People’s privacy and dignity was maintained at all times.
People and relatives, where appropriate, were involved in the planning of their care and support. People were supported to follow their interests and join in meaningful activities. They knew how to make a complaint and there was a complaints procedure in place which was accessible to all.
There were effective management and leadership arrangements in place. Systems were also in place to monitor the quality of the service provided. Action plans were in place and were updated after checks and audits, to help further develop the service. The registered manager also submitted statutory notifications to the CQC when required.
We carried out an unannounced comprehensive inspection of this service on 27 May 2015 and rated it ‘Good’.
We carried out this focused inspection on 23 September 2016 following receipt of concerning information to the Care Quality Commission (CQC). We received concerns in relation to the care people were receiving and the management of the service. In addition, concerns had been raised about the nutritional status of the meals provided and that people’s health needs in relation to wound and pressure care were not being met. We also received concerns regarding the level of staff working at the service meaning that people were not always supported by sufficient members of staff on duty. We therefore needed to ensure that people’s care was being delivered in line with the fundamental standards.
This report only covers our findings in relation to those concerns raised. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Burlington Hall Care Home on our website www.cqc.org.uk.
The service did not have a registered manager at the time of our inspection; however a new manager was in post who had commenced the process to register. 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.
People felt safe in the service. Staff were aware of the safeguarding processes and were able to demonstrate their knowledge. Appropriate referrals had been made to the local authority when concerns had been raised.
Personalised risk assessments were in place to reduce the risk of harm to people and these were reviewed regularly. Accidents and incidents were recorded and the causes of these monitored and analysed so that preventative action could be taken to reduce the number of occurrences.
There were sufficient numbers of staff on duty to meet people’s needs. People’s needs had been assessed and consideration had been given to the layout of the building when determining the numbers of staff deployed on the rota.
People had a variety of nutritious food and drink available to them. A varied menu was available and people had a range of meals to choose from. Snacks and fruit were available to people at points throughout the day. People had been asked their likes and dislikes and members of kitchen staff were informed of, and regularly updated with regards to, people’s preferences and dietary requirements.
People’s health needs were being met and they received support from health and medical professionals when required. Records in relation to people’s health and well-being were up to date and comprehensive.
There was a clear management structure of senior staff and staff felt supported in their roles. People, relatives and staff knew who to raise concerns with and there was a positive culture. The provider had effective quality monitoring processes in place and feedback about the service was encouraged. The provider had an active role in the management of the service.
During this inspection, we were unable to substantiate the concerns raised, therefore there were no changes to the rating of ‘Good’, and no breaches of regulation were identified.
Burlington Hall Care Home provides care and support for up to 53 people who are physically frail some of whom maybe living with dementia. There were 49 people living at the service when we visited.
The inspection of Burlington Hall Care Home took place on 27 May 2015. It was an unannounced inspection as a result of information the Care Quality Commission (CQC) had received. On this occasion we were unable to substantiate the concerns that had been raised.
The home has a registered manager. ‘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.’
People were looked after by staff who were aware of how to respond to allegations or incidents of abuse.
The staffing numbers at the service were adequate to meet people’s assessed needs.
The service had a recruitment process to ensure that suitable staff were employed to look after people safely.
Suitable arrangements for the storage and management of medicines were in place.
Staff received appropriate support and on-going training to perform their roles.
People’s consent to care and treatment was sought in line with current legislation. Where people’s liberty was deprived best interest assessments had taken place.
People were provided with a balanced diet and adequate amount of food and drinks of their choice. If required people had access to health care services.
People were looked after by staff who were caring, compassionate and promoted their privacy and dignity.
People’s needs were regularly assessed and reviewed to ensure that the care they received was relevant to their needs.
There was a complaints process which people were made aware of.
The service promoted a culture that was open and transparent. The management and leadership at the service were visible.
Quality assurance systems were in place and these were used to obtain feedback, monitor performance and manage risks.
Burlington Hall Care Home is registered to provide accommodation and support for 53 people with a variety of care needs, ranging from frail elderly to people living with dementia. On the day of our visit, there were 49 people living in the home.
The inspection was unannounced and took place on 5 November 2014.
The service has a registered manager. 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 and associated Regulations about how the service is run.
The eight people we spoke with told us they felt safe within the home and because of the care that staff provided them with. They told us that the staff were caring and respectful and met their needs. Our observations confirmed this and we found that there were effective systems in place to protect people from the risk of harm.
Systems were in place to ensure that medicines were stored, administered and handled safely. Staffing arrangements meant there were enough staff to manage medicines appropriately and to meet people’s needs safely.
The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. Through our discussions, we found staff demonstrated that they understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards. This meant they were working to support people who may lack capacity to make their own decisions. The registered manager had a good knowledge of the Deprivation of Liberty Safeguards (DoLS) and advised us that they had made applications to apply it in practice.
Staff understood the needs of people and we saw that care was provided with kindness and compassion. People and their relatives all spoke very positively about the home and the care that people received.
Staff told us they received on-going training and we found through our discussions, that they were appropriately trained and understood their roles and responsibilities, as well as the values of the home. They said that they had completed ongoing training to ensure that the care provided to people was safe and effective to meet their needs. Staff also told us they had robust support, induction and supervision that was relevant to the needs of the people who lived at Burlington Hall Care Home.
People received effective support around their personal needs and we found that staff supported people to maintain their mobility and nutritional needs.
People had access to healthcare professionals when they became unwell or required help with an existing medical condition. We found that people’s ability to remain independent was encouraged and people were supported to access activities that they enjoyed within the home and wider community.
All eight staff spoke positively about the support they received from the registered manager. Staff told us there was a good level of communication within the home which helped them to be aware of any changes. People told us they found the staff and management approachable and knew how to raise complaints and concerns.
The provider had a robust recruitment process in place. Records we looked at confirmed that staff started work in the home after all recruitment checks had been satisfactorily completed. Staff we spoke with told us that they had not been offered employment until these checks had been confirmed.
We found that the service was well-led and that staff were well supported and consequently motivated to do a good job. The registered manager and senior staff consistently monitored and reviewed the quality of care people received and encouraged feedback from people and their representatives, to identify, plan and make improvements to the service.
People using the service expressed satisfaction with the care they received. They told us they were well looked after by all the staff. One person said 'Staff are excellent and good to everyone'. They also said 'You have only got to ask and it's done'. Another person said the staff 'Help me get washed and dressed' and 'they are very nice'.
The relatives we spoke with told us that Burlington Hall was 'lovely and clean'. They also said 'The staff are very good and caring' and looked after their family members needs well and they would recommend the home to other people. They also told us that the staffing levels at the home had improved and they had been involved in reviewing their relatives care needs.
Throughout our visit we observed people using the service had a good relationship with the staff and they spoke to people in a dignified and kind manner. The staff told us that they had a new manager and they felt supported by them.
We found the provider had put systems in place to meet people's health and welfare needs. People had individual care plans which were supported by risk assessments and daily care records to meet their needs. We also found that there were sufficient numbers of skilled staff to meet people's needs. We saw that the provider had systems in place to monitor and review the quality of service that was provided to people using the service.
We used a number of different methods to help us understand the experience of people living at Burlington Hall. This was because some of the people living there had dementia, and we were not able to have meaningful conversations with them.
Most of the relatives we spoke with provided positive comments about the home. Some of the comments included 'The staff are fantastic and very caring'. 'I have seen the care plan and I am involved in her care'. 'If my mother has a fall or they are not well, the staff rings me to let me know what happened'. 'If I have any concerns I will speak to the staff and they listen'.
We also observed that the staff on duty had a calm and kind manner when working with individual people. Several people in the dementia unit were not able to hold meaningful conversations with us, but we saw from their responses and body language that they were happy with the way staff were treating them.
The people we spoke with told us that they liked the staff and they spoke to them in a kind manner. One person told us 'Staff are very nice' and they liked the activities'. Another person told us that they felt well looked after by staff and noted 'It's as good as you can get'.
However, we found that in the Larchwood unit people's care plans were not always being updated when the needs of the people changed. A warning notice was issued because people's care and treatment needs were not always being met. There were also not enough staff to meet the needs of people in the mornings. The monitoring systems put in place to find out if people's needs were being met were not fully implemented. .
We observed people enjoying their meal at lunch time on Maple and Larchwood Unit. We were told by most people that the meals were very good and tasty. We saw that people were provided with two hot choices of meals and an alternative choice was also available.
We saw that people who used services had care planning documents to tell staff how to meet their needs; however the plans were not being updated to ensure information was up to date. We also found that there were some times not adequate numbers of staff on duty to meet people's needs. The staff did not always receive staff supervision meetings with their manager to look at how they were meeting people's needs and their personal development needs. We found that people did not receive their medication at the time they needed to ensure their health care needs were being met.
The inspection team was led by a CQC inspector and a practicing professional.
During our inspection visit to Burlington Hall Care home we met a number of people who used the service. We spoke with several people living at the home as well as one visiting family to ask them for their views on the service they received at the home. We also spoke to the manager and five care staff on duty.
We used a number of different methods to help us understand the experience of people living at Burlington Hall. This was because some of the people living there have dementia, and we were not able to have meaningful conversations with them.
During our observations we spoke with a family that gave positive comments about the home and the level of care that was given by all staff to their family member who was ill. They said that staff were very caring and that their relative was happy living at the home. They told us that they thought that the home was nice.
We observed that all staff on duty had a calm and kind manner when working with individual people. Several people in the dementia unit were not able to hold meaningful conversations with us, but we saw from their responses and body language that they were happy with the way staff were treating them. We saw that people's privacy and dignity was maintained when people were assisted with personal care needs.
Some of the comments that people we spoke with told us were 'The attitude of staff is very good', 'I am well looked after medically and staff respond well to you if you are unwell, including access to chiropodist; dentist; optician' and 'The home management are very approachable'. All the people we spoke with told us that they liked the staff and were spoken to in a dignified manner. Several people told us that the food on the whole was nice, and they were asked about food menus in the resident's meetings.
However, we found that there were not enough staff to meet the needs of people in the dementia unit when we observed people having lunch. We also found that information about an incident that took place at the home was not available and we were therefore unable to find out if the relevant authorities had been informed about the incident and what actions were put in place by the provider to keep people safe.
People said that the care plan was based on their individual needs and it was reviewed regularly. They told us that staff supported them to maintain contact with family members. Access to health care facilities were available. People said that they were provided with a choice of meals. If they did not like the choices on the menu an alternative would be provided.
People told us that the staff team provided a high standard of care and ensured that their medicines were given at the appropriate time. Staff made their visitors feel welcome and provided them with refreshments. People said that their bedrooms were comfortable and cleaned regularly.