Burton Closes Hall Care Home

Burton Closes Hall Care Home is a residential care home providing accommodation for up to 58 people who require nursing or personal care. This includes both older and younger adults who may be living with dementia and/or a physical disability. At the time of this inspection there were 27 people living at the service, including 17 people receiving nursing care. This included 2 people with learning disabilities, whose primary care needs related to their physical health conditions. The service provides single room accommodation, including some en-suite, over 2 floors within 1 adapted building.

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

Risks to people's safety associated with their environment, health condition and any equipment used for their care, were effectively managed and mitigated. People’s medicines were safely managed to ensure people received their medicines when they should.

The provider was meeting key principles for infection prevention, control and cleanliness at the service, including for COVID-19. The provider's safeguarding, emergency contingency planning and staffing measures, helped to ensure people’s safety and protect them against the risk of harm or abuse.

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.

We expect health and social care providers to guarantee people with a learning disability, respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting any person with a learning disability and providers must have regard to it. The service was able to demonstrate how they were meeting the underpinning principles of Right support, Right care, Right culture to ensure people’s needs could be fully met.

The provider's governance arrangements were now wholly effective, to regularly check the quality and safety of people's care and ensure timely service improvement, when needed.

The service was well managed. Managers and staff understood their individual role and responsibilities for people’s care and regulatory requirements were being met. Related communication, reporting and record keeping procedures, helped to ensure this.

There was an open, positive and inclusive culture at the service, where people felt they mattered and staff were supported and motivated to provide people’s care in the right way.

The provider worked in partnership with people, relevant authorities, care partners and others with an interest in people's care at the service. Related consultation and feedback was used to help inform and improve the service, when needed.

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: 12 August 2022) and there were breaches of regulation. The provider completed an action plan following the last inspection; to show what they would do and by when, to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. We checked whether the Warning Notice we previously served, regarding a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, had been met. This report only covers our findings in relation to the Key Questions Safe and Well-led, which contain those requirements.

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 COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last full comprehensive inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Burton Closes Hall Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Burton Closes Hall is a residential care home providing accommodation for up to 58 people who require nursing or personal care. This includes both older and younger adults who may be living with dementia and/or a physical disability. At the time of this inspection, there were a few people with either a learning disability or an enduring mental health condition, with a primary care need of nursing care relating to their physical health conditions. The service provides single room accommodation, including some with en-suite provision over two floors within one adapted building. At the time of this inspection there were 25 people using the service.

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

The provider’s governance arrangements, were still not effective to consistently ensure the quality and safety of people's care and for timely decision making, risk mitigation and service improvement when needed. Related records were not always accurately maintained.

Risks to people's safety were not always effectively managed and mitigated. Medicines were not always safely managed to consistently ensure people received their medicines when they should and we found risks regarding the provider's fire safety and related emergency arrangements at the service. We were mostly assured the provider was meeting key principles for infection prevention and control at the service, including for COVID-19. However, some areas of environmental and equipment cleanliness were not proactively ensured, until we raised this with the provider.

Staff were safely recruited and understood nationally recognised safeguarding principles and local procedures for people’s care. However, staffing arrangements, including areas of training and for staff supervision were not wholly assured. We signposted the provider to help them review and develop their staffing and workforce arrangements for people’s care.

People were often supported to have maximum choice and control of their lives. However, the provider was not able to fully demonstrate that decisions made for some people’s care with regard to their daily living arrangements, were lawful, least restrictive and in people's best interests.

We expect health and social care providers to guarantee people with a learning disability, respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting any person with a learning disability and providers must have regard to it. The service was not able to fully demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture to ensure individual needs could be fully met.

The provider regularly sought the views of people, relatives and staff. However, timely follow up to address outcomes from this was not always demonstrated. People, relatives, staff and external health professionals we spoke with were often happy with the service and arrangements for people’s care. However, many felt further improvements were needed, to fully ensure the quality and safety of people’s care and optimise people’s care experience.

Staff were kind, caring, knew people well and had good relationships with them and their families. Staff understood many aspects of their role and responsibilities for people’s care. They were responsive, to ensure people’s access to relevant external health professionals when needed and regularly provided care in a personalised way. Risks to people's safety associated with their health conditions, were often effectively managed, although we found record keeping anomalies relating to two peoples' nutritional needs we looked at, where risk information was not accurately recorded, to safely inform their care.

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 25 May 2019) and there was a breach of regulation. The provider completed an action plan following the last inspection, to show what they would do and by when to improve. At this inspection sufficient improvements had not been made and we found breaches of regulation in relation to safe care and treatment and governance. The service remains rated as requires improvement. This is based on the inspection findings. The service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

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 COVID-19 and other infection outbreaks effectively.

This was a focused inspection prompted by a review of the information we held about this service; to check the provider had followed their action plan to rectify the breaches we found at our last inspection of this service in May 2019, and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led, which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Burton Closes Hall Care Home on our website at www.cqc.org.uk

You can see what action we have asked the provider to take at the end of this full report.

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 monitor the service and will take further action if needed.

We have identified breaches in relation to safety, management and leadership at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service:

Burton Closes Hall is a care home that provides personal care and nursing for up to 58 people. The accommodation is established over two buildings. However, the provider has taken the decision to only use one building. This building is set over two floors. There are communal spaces on the ground floor and access to a secure outside space. There are bedrooms on both floors with bathing facilities. At the time of the inspection there were 26 people using the service.

People’s experience of using this service:

The provider had completed audits to support the quality of the home, however some areas had not been addressed swiftly to reduce the impact on the person. Other areas which had been identified had not been followed up to ensure any changes were embedded. People’s views had been obtained, however no action had been taken to consider how to address any required outcomes or how to share the information.

People using the service were not always supported to have meaningful activities in relation to their hobbies or interests. The environment did not provide orientation guidance for people living with dementia or information in different formats.

There were enough staff to support people’s personal needs, however there were not always enough staff to support the opportunities for interactions or required paperwork.

There was a choice of meals and dietary requirements were catered for. However, the provider recognised that further work was required in this area to make the meal times a more social experience.

Staff had been recruited appropriately to ensure they were suitable to work with people. There was an established group of staff who knew people well. This enabled them to provide care which was personal and supported people’s daily choices and preferences.

People’s dignity was maintained, and consent obtained before care was provided. 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 service support this practice.

People’s health care was supported with established partnerships from a range of professionals. Information about people’s care was only shared with those relevant or at the persons permission. Relatives were made welcome at the home.

Any risks had been assessed and measures put in place to reduce the risks. Medicines was managed safely and in line with current guidance. People were protected from the risk of harm with staff having training in safeguarding and understanding the importance of reporting any concerns.

Staff had received training for their roles, which enabled them to develop their skills in providing care which was in line with current guidelines to ensure safety and good practice. Lessons had been learnt from events.

Care plans were detailed and reflected the individual’s needs to support their care, this included any religious or cultural needs. There were regular services provided from the local religious denominations.

There was a complaints policy which was used to address any concerns raised. The providers rating was displayed on their website and within the home as required. We had received notifications of events and incidents and this enabled us to reflect on the action the provider is taking to ensure people’s ongoing safety.

Rating at last inspection: Requires Improvement (Published June 2018)

Why we inspected: The inspection was prompted in part by notifications and concerns raised by relatives and health and social care professionals. At this inspection we found the service continues to be ‘Requires Improvement.’

Enforcement: We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.

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 time of our inspection there was no registered manager in post, however the manager had applied for registration and was registered on 4 April 2018. They were present at the inspection. The service is required to have 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.

There was enough staff available to meet people’s basic needs. The service was reliant on agency staff and people were not always happy with this. Care was not always personalised and people did not have their needs and wishes beyond basic needs met.

Staff had been trained in safeguarding and understood how to raise any concerns. Recruitment processes were in place to ensure any new staff would be subject to pre-employment checks on whether they were suitable to work at the service.

Appropriate arrangements were in place for medicines management and these followed procedures designed to ensure safe medicines practice. People were offered their medicines as prescribed.

Processes were in place to ensure risks and people’s health needs were assessed, managed, monitored and responded to. The premises had been adapted in ways to make sure it was suitable for people using the service. However this was not always successful leaving some people cramped in small communal areas and others isolated in very large communal areas.

People’s needs and choices were promoted in a way that prevented and reduced the impact of any discrimination. People’s communication needs were assessed and people were supported to communicate effectively with staff. The Accessible Information Standard was being met. Staff knew how to support people to make decisions and ensure their rights were respected, working in line with the principles of the Mental Capacity Act 2005.

Due to the high use of agency staff people were not always supported to have maximum choice and control of their lives.

Staff in post were trained and were well supported. Staff were caring in their interactions with people. However care was not always delivered in a manner that promoted people’s dignity and independence. People were not offered the opportunities to pursue their different interests and hobbies and contact with the local community was poor.

People felt able to raise any issues or concerns. There was a complaints process in place to manage and respond to any complaints should they be made. The service had received many compliments.

The manager was aware of the issues to be addressed and had started to make progress on recruitment and more stimulation for people. The provider and the manager had audits and checks in place to provide assurances for the governance of the service. Policies and procedures had been updated to reflect the needs of the service.

This is a summary of what we found.

Is the service safe?

Our previous inspection visit in October 2013 found that people's consent to their care and treatment where they did not have capacity to make decisions was not being sought within the legal framework of the Mental Capacity Act (MCA). At this inspection we saw some improvements had occurred and initial capacity assessments were in place on the records we looked at. However, these were not signed in all cases and it was sometimes unclear how the information had been obtained and who had supplied it. This meant the service continued to not fully meet the requirements of the MCA.

Our previous inspection visit in October 2013 found that there were areas of the premises that were not clean and infection control practice did not always reduce the risk of infection. We found there had been some improvements on this inspection visit but there were still areas that required improvement, such as cleanliness in people's rooms.

We found medication procedures had improved since our previous inspection in October 2013 and people were receiving their medication as prescribed.

We found the building was safe for people to use but its design was not suitable for people with dementia. For example, people were not able to access external space easily and communal areas were small so people were restricted in how they were able to move around.

Is the service effective?

Our observation of people's care found that most staff were caring and helpful but we saw that there were occasions where less of the staff's attention was given to people who had cognitive impairments and to those who were less able to communicate. One person said 'They only come in when they have to. I spend most of my time on my own'. Another person we spoke with had poor oral hygiene, with their teeth appearing encrusted and there was the remains of food on their bed. This meant the care provided was not always effective to all people who used the service.

Care records had improved since our last visit in October 2013. We saw they were reviewed regularly and where a risk assessment was in place for issues such as nutritional needs or falls, there were corresponding care and support plans. We saw people's weight was monitored on a regular basis. This meant appropriate records were in place for the provision of care.

Is the service caring?

People we spoke with were mostly complimentary about the care; one person and their relative both told us 'Staff are very respectful' and another person said 'I like it here very much. Everybody is very kind and respectful'. Another person said 'I enjoy every minute of it'.

Our observation showed staff had warm relationships with people and interactions were mostly helpful and caring.

Is the service responsive?

People told us they did not have to wait long for assistance from staff. One person said 'I don't have to wait long' and another person said "If I ask staff for anything they help". A relative told us there seemed to be enough staff when they visited.

We saw that external health professionals were called in as required and one told us 'They have a made a big effort recently' and 'It's really improved'.

We found staff had access to suitable training and support. This meant staff received appropriate guidance to work safely.

Is the service well led?

People were asked for their opinions of the service and were able to make comments and suggestions.

We found staff received sufficient training and support to enable them to do their job.

We found there had been some improvement in monitoring the quality of the service on this inspection visit but there were still shortfalls in the auditing process as it had failed to identify the issues of concern we found on this visit. This meant the service was not always managed in the best interests of the people using it.

Record keeping had improved and we saw people's personal records, including medical records, were accurate and fit for purpose.

We found consent was not always obtained for people's care. If people were unable to make their own decisions, correct procedures were not being used.

Although assessments were completed, the provider was not ensuring people received safe, appropriate care that met their specific needs. We found that records were not full and accurate and also that they were not securely stored.

We saw measures for infection prevention and control were in place but found they were not adequate to fully protect people from harm. We also found the premises were not adequately safe to protect people from risk. We found that appropriate arrangements were not in place to fully manage the risks associated with medicines.

Although systems were used to assess and monitor the quality of service provided at the home, these were not always adequate to identify and manage risks.

Staff were provided with training and supervision. Nursing staff, however, did not receive adequate support to maintain and develop their skills. We found that sufficient numbers of staff were available to provide people's care at the home.

The Health and Safety Executive (HSE) inspected the home on 16 October 2013 and found concerns that are also referred to in this report.

At our last visit to Burton Closes Hall on 24 September 2012 we found that there were not enough qualified, skilled and experienced staff to meet people's needs.

We did not speak to people using the service for this follow up review. We undertook focused observations of staff interactions with a group of four people during our visit, using our Short Observational Framework for Inspection (SOFI). We observed that people's needs were generally met and people interacted positively with members of staff.

We reviewed the staffing rota's for all three units in the home for the six weeks before our visit. We found that staffing levels in all three units had improved and that the numbers of staff on shift at any one time had become more consistent.

We saw that in general, staff interacted positively with people living at Burton Closes Hall however we saw that staff do not always have the time they need to meet people's needs. We found that staffing levels of care staff working in two areas of the home were inconsistent and that there were insufficient numbers of staff to meet people's needs and ensure their health, safety and welfare.

We saw that menu's in the home had been reviewed and that there was an increased choice of food available. We saw that the menu changes had been discussed with people living at Burton Closes Hall.

We found that the provider had taken appropriate action following our last inspection to ensure that they were regularly assessing and monitoring the quality of service people were receiving. We saw that a number of audits had been completed for areas such as infection control and medications. Appropriate action plans had been put in place following the audits and were being addressed by the provider and the home manager.