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Burlingham House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 June 2019

About the service: Burlingham House is a care home providing personal care for up to 49 older people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. This service does not provide nursing care. 34 people were being supported on the day of our inspection. Our inspection focused upon the key questions of safe and well-led.

People’s experience of using this service:

• Since the previous inspection, the staff had acted upon the concern we raised and had made improvements to the care planning of people nearing the end of their lives.

• At this inspection we found the provider’s systems had not always identified areas of concerns regarding the monitoring of people’s care when they were there for a short time of respite care.

• Although daily notes reported that a person was eating well, they had lost a considerable amount of weight while at the service. This had not been identified by the staff.

• The staff had not reported to the local authority safeguarding team or the Care Quality Commission in good time that a person had lost a considerable amount of weight whilst in their care.

• The service used a dependency tool to determine how many staff were required to be on duty to support people.

• Staff informed us there were sufficient staff on duty and they had time to care for the people living at the service.

• The service had a robust recruitment process in place.

• The staff carried out and recorded fire tests and clearly logged that equipment such as hoists and weighing scales were checked appropriately to be working effectively.

• Staff had received training in the care needs of people with dementia and were further supported with supervision.

• The service had quality monitoring systems in place, but these had not always been effective.

• The service met the characteristics for a rating of “Requires Improvement” in the key questions of Safe and Well-Led. Therefore, our overall rating for the service after this inspection has changed from “Good” to “Requires Improvement.”

Rating at last inspection: Good. The report was published on 12 December 2018. All key questions were rated as Good other than Responsive which was rated as requiring improvement.

Why we inspected: We became aware of concerns about the quality assurance process used by the service regarding the monitoring and taking appropriate action over a person’s weight loss. We were also concerned about reporting this information within an appropriate time to the local authority safeguarding team and Care Quality Commission.

Follow up: We will continue to monitor intelligence we receive about this service until we return to visit as part of our re-inspection programme. If we have any concerns, we may inspect sooner.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 12 June 2019

The service was not always safe

Details are in our Safe findings below.



Updated 12 December 2018

The service was effective.

Staff received training relevant to their roles.

People received a choice of balanced meals and enough to drink.

Staff supported people to access healthcare and followed recommendations where needed.

People�s mental capacity was assessed for making specific decisions, and these were made in people�s best interests where needed. Where people were deprived of their liberty, this was compliant with relevant legislation.



Updated 12 December 2018

The service was caring.

Staff and people had built good relationships and staff respected people�s privacy and dignity.

People and their relatives were involved in making decisions about people�s care.

People were supported and encouraged to have visitors to the home when they wished.


Requires improvement

Updated 12 December 2018

The service was not always responsive.

Care plans contained guidance for staff on meeting people�s individual needs and preferences, and included information about people�s interests. However, further information around supporting people with their health conditions and end of life care was needed.

People and their relatives were asked for feedback on the service, and people knew who to speak to if they had concerns.


Requires improvement

Updated 12 June 2019

The service was not always well-led

Details are in our Well-led findings below.