Burleys Wood

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 requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager did not always have a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety; however, concerns about safety were not consistently investigated and recorded. Lessons were not always learnt to continually identify and embed good practice.

Staff recognised incidents and some of these had been reported and recorded appropriately. However, staff told us they have been told not to record all incidents. Staff who provided feedback gave specific examples of people’s behaviours they were discouraged from recording, this included, ‘Residents who are very disruptive towards other residents.’

Records demonstrated that there were some accidents and incidents that had been investigated appropriately to ensure actions were taken to reduce the risk of recurrence.

People’s care plans were updated in response to recorded incidents. This ensured practice was reviewed in response to these recorded incidents and changes were made to improve the service. However, some staff told us that their concerns were routinely dismissed and they were ignored. This led to a culture which prevented some staff from being able to speak up and prevented a learning culture.

Following the assessment, we discussed the feedback received from staff with the provider. The provider told us of the mechanisms they had put in place to facilitate staff feedback. They provided assurances they would take action regarding the feedback from staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff worked with external professionals to ensure people’s needs were suitably met. This included making appropriate referrals to other health and social care services where needed to enable people safe continuity of their care. People were supported appropriately with health appointments.

Visiting healthcare professionals provided positive feedback which included, “There is consistently good staff” and, “Instructions are followed.”

The provider did not always work with people and healthcare partners to understand what being safe meant to them and the best way 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 and appropriately.

There were systems and processes in place to identify, review and investigate safeguarding matters. However, staff told us they were discouraged from reporting some incidents. Records showed appropriate action had been taken with regards to all recorded safeguarding concerns. Documents showed the registered manager maintained oversight of the recorded safeguarding concerns and ensured learning was shared.

There was a whistle-blowing policy so if staff had concerns, they could report these. However, some staff who provided feedback were not confident their concerns would be listened to and expressed a fear of repercussions should they raise concerns. Feedback from staff included, ‘I do hope this stays confidential as things will be made very hard for me at work’ and, ‘[Staff are] worried details will be shared which will make things very difficult for people at burleys wood.’

Following the assessment, we discussed the feedback received from staff with the provider. The provider told us of the mechanisms they had put in place to facilitate staff feedback. They provided assurances they would take action regarding the feedback from staff.

The registered manager kept track of those who were under Deprivation of Liberty Safeguards (DoLS) and, when these needed to be renewed, had made appropriate referrals. Where people had conditions attached to their DoLS, for example medication reviews, we saw that these were followed.

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

Staff knew people well which enabled them to provide appropriate safe care. Some risks to people were assessed on admission to the service and updated regularly. Actions were in place to mitigate some of the risks to people. For example, where people were at risk of weight loss, fortified supplements and snacks were offered. Some staff told us they felt discouraged from reporting changes in people’s needs that might require a new risk assessment or additional staffing. This included some incidents where people, ‘display physically and verbally aggressive behaviours towards other residents and staff.’ A member of staff told us that they were, ‘Concerned that staffing levels do not adequately reflect the complexity of residents’ needs.’

People told us they were involved in making decision about their care. Care plans considered risks to people. Guidance was provided to staff in how to minimise risks to people. Feedback from visiting healthcare professionals included, ‘Residents at Burleys Wood appear safe and protected from harm. The home has its own policies and care plans in place, and risks are generally well mitigated. Staff seek advice appropriately when required.’

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The registered manager had a robust routine of environment checks in place.

Appropriate maintenance audits were effective and completed within the allocated and suitable timeframes to promote a safe environment. Checks such as fire alarm and water safety were completed regularly.

Feedback from visiting healthcare professionals included, ‘People’s rooms are clean.’

The provider did not always make 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.

Staff raised concerns to us regarding the staff levels at Burleys Wood. Feedback from staff included, ‘My main concern is that we are not consistently meeting the needs of residents due to ongoing staffing shortages, particularly during night shifts.’ Another staff member told us, ‘It is hard to meet the needs of the residents, and the staff are working in pressure to give care to the residents.’

A further staff member told us, ‘The issue is when staff call in sick, which is happening almost daily at the moment, especially at weekends, we are not using agency as we have overspent. Staff are feeling very exhausted and tired, residents care is rushed and their needs are not being met in the morning due to staffing issues. Residents are having to wait [for personal care]. The second day you inspected extra staff were brought in and put on shift which is not a true representation of how we are working, the home’s budget appears to be top priority over the resident’s needs.’

Feedback from relatives included, ‘The carers do their best. We understand that they are also very busy. When [Name] presses the call bell it can take some time. [Name] tends to go and get someone, and they are also busy when [Name] goes to find someone.’

The registered manager told us that staff numbers were appropriate. They said they were calculated according to people’s dependency scores, and people’s care records included their individual dependency scores. However, staff raised concerns and told us, ‘They do not look at the needs of the residents but the number of residents. So, staff keep rushing to finish work and residents are rushed to do things because other residents are waiting. Some residents complain too. They say they wait too long or are being rushed.’

People we spoke to did not make any comments regarding the staffing numbers, although several staff members reported pressures relating to staffing levels.

During our visit we saw that some staff were not relaxed. They appeared rushed and told us they were not able to spend time with people. Feedback from staff included, ‘Staff cannot sit down in the living room because management will take out staff members and say we manage.’

Staff also raised concerns regarding the culture at the service. Feedback included, ‘Everyone [staff] feels unheard. Staff feel very unvalued. The turnover of staff is huge. New staff don’t stay or they change their contract to bank, most of the staff who are long term are because of sponsorship… I do believe everyone including staff and managers wants the very best for our residents but with staffing issues and staff not being heard it’s not happening… I hope this stays confidential as things will be made very hard for me at work, but I do believe if staffing issues change, the home could improve hugely.’ We did not find any evidence that staff turnover was high. Feedback from another staff member described some of the senior staff as, ‘intimidating’, ‘caustic’ and, ‘sharp tongued.’ They said, ‘[Senior staff] like giving orders instead of guidance.’

New staff received induction training which led on to a comprehensive plan of training. Staff had undertaken training in topics specific to the people living at the service including, dementia care and behaviours that challenge (distressed behaviours). The registered manager kept oversight regarding staff training to ensure this was kept up to date. Competency checks were completed to monitor staff knowledge and practice. Staff gave positive feedback regarding their training.

Staff were recruited in line with safe practice. For example, checks were made to ensure staff were of good character and suitable for their role. This included obtaining references from previous employers. Checks with the Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

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

Staff received training on infection control, they were trained in the use of Personal Protective Equipment (PPE). We saw staff using this when needed. However, some staff raised concerns regarding PPE. Feedback from staff included, ‘I am also worried about decisions that appear to prioritise cost-saving over care delivery. For example, staff were informed that glove usage was too high, despite a previous shortage of PPE within the home. At one point, PPE supplies were extremely limited, which had a significant impact on safe practice. As a care environment, appropriate PPE use is essential for infection control and resident safety.’ A second staff member said, ‘There is an ongoing shortage of PPE, with the manager seemingly limiting supplies to save money. Staff are sometimes compelled to reuse items or work without adequate protection. This practice is unsafe and breaches infection control standards.’ Another staff member provided feedback which included, ‘PPE is consistently available.’ We have not been able to corroborate the concerns staff raised regarding a lack of PPE as they did not provide us with specific dates or times when the issues they raised had occurred.

Following the assessment, we discussed the feedback received from staff with the provider. The provider told us about the actions they were taking in response to this assessment. They said, ‘Our Head of Hotel Services attended the service unannounced last week to review the PPE concerns raised; [they] found stock levels were sufficient but provided guidance on adequate stock levels based on the staff on shift.’

Infection control audits were completed and people told us they were happy with the cleanliness of the service. Visiting healthcare professionals who provided feedback did not raise any concerns regarding infection prevention and control at Burleys Wood.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicines were stored and administered safely. Medicines were stored securely following current guidelines for the storage of medicines. There were dedicated rooms for storing people’s medicines. The storage facilities were clean and organised. There were lockable fridges to store medicines that required lower storage temperatures. Daily temperatures of the fridge were taken and recorded to ensure the fridge remained at a safe temperature.

Each person had an electronic medication administration record (MAR) detailing each item of prescribed medication and the time they should be given. People did not raise any concerns regarding the administration of their medicines.

Staff had received training, and competency checks were completed to ensure staff were suitably skilled to do their roles. All the staff we spoke to regarding the administration of medicines told us they felt confident and competent.

Feedback from visiting healthcare professionals was positive and included, ‘Medication management is well organised. During medication rounds, team leads and nurses wear red tabards to indicate they should not be disturbed, and this is consistently respected. When a resident is unable to take medication all at once, staff revisit this rather than omitting doses. MAR charts and discharge summaries are kept up to date and shared promptly with visiting professionals. Residents on high-risk medications (such as insulin, anticoagulants, and opioids) are monitored appropriately. Homely remedies are used (to my knowledge) in line with clear protocols, and staff make effective use of body maps and pain charts to support clinical decision making.’