Burley Hall Care Home

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. This is the first assessment for this service under this provider. This key question has been rated Good.This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. The manager listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff told us the management team were supportive and listened to and investigated any concerns. Comments included, “The manager is very nice we can communicate well with them. I am very happy with the new manager. They come [on] to the floor and check everything is ok. They are a visible manager.”

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. The manager confirmed a pre-admission assessment was completed to ensure the service could meet the needs of the person. They then obtained a summary from their GP. Following admission into the home people were closely monitored with an emotional support plan in place for 7 days. We saw evidence of appropriate pre-admission assessment paperwork. People were positive when asked about their transition to the home. Comments included, “[Relative] has only been here a couple of weeks, they showed us around slowly and answered all questions. They were very good.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Robust safeguarding procedures were in place. Safeguarding concerns were investigated and responded to in a timely manner. The required statutory notifications had been submitted to CQC.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things that mattered to them. Care plans were person-centred, and people told us they were involved in their care. Comments included, “They have been through the care plan and medication, and they keep me updated.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. There was a sluice and storage cupboard containing hazards; both had locks which were broken. This was rectified during our assessment. There were storage issues within the home with hoists and other equipment stored in hairdressers, bathrooms and corridors. The external environment required some attention. There were cobwebs on windows and overturned plant pots. The provider was completing ongoing maintenance work of the garden during our assessment. Health and safety checks had been completed. Where water temperatures were too high, we provided feedback and were assured this would be addressed. Two people raised concerns their relatives did not have call bells in their room. We checked the persons records and it stated in their risk assessments they were unable to use a call bell. The relatives did not agree with this. The home said they would investigate this.

The provider did not always make sure there were enough qualified, skilled and experienced staff. The homes training matrix identified some staff were not up to date with their mandatory training. No concerns were raised from people in relation to staffing levels. Most staff members were happy with staffing levels, but some staff members felt the home was understaffed. Comments included, “I think we have enough staff yes” and “Yes, we are short staffed. We think we are anyway, but the company say not, but think you’d find that in any care home."

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. There were infection prevention and control (IPC) policy and processes in place. All areas of the home were clean, and we observed staff wearing PPE. People said they were happy with IPC within the home. Some comments included, “It is very clean, they come in clean” and “It’s spotless, they come every day and clean, they dust everywhere, and bedding is also cleaned.”

The provider made sure 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 and stock balances were correct. People were receiving their medicines on time and the homes treatment rooms were clean and tidy. Care plans and protocols had sufficient information to assist staff with caring and administering medicines correctly. The home had developed good processes to ensure they were not carrying more medicines than needed. People raised no concerns in relation to medication when we asked.