Burwood Grange 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 newly registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and accidents, safeguarding concerns and complaints were recorded. These were reviewed, discussed and analysed to determine any underlying causes or trends and to identify any actions required to improve the service. For example, when a recent medicines error was identified during an audit, a full investigation had been carried out and the staff involved were undertook further training and had their competencies assessed before being able to continue with administering medicines to people.

The managers had regular quality assurance monitoring meetings to share good practice, what worked well, and to identify trends and analyse where improvements were needed.

The registered manager understood their responsibility under the Duty of Candour and was able to demonstrate how they had acted on this.

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 told us they received information about a person before they were admitted to the home, so they could understand and meet their needs and wishes. However, one person told us, “The new carer did not know anything about me. You have to guide them. [They were] like a frightened little rabbit. It isn’t [their] fault. There is no co-ordination.” We fed this back to the provider. They told us, “All new starters have a two-week shadow shift induction where they buddy up with another carer before being on the floor as a counted member of staff. They also have full access to the electronic care system.”

Relatives stated they were informed when their family members required support or treatment from different healthcare services.

The staff team and registered manager told us they worked well with other professionals to ensure continuity of care. Healthcare professionals told us they had a good working relationship with the service and communication was 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.

People told us they felt safe living at the home. One person said, “Oh yes, it is safe. My friends say it is like a five-star hotel.” Relatives felt their family members were safe from harm and abuse. A relative told us, “[Family member] is very happy – it’s a lovely place. We know [they are] safe here and that is the main reason that [they are] here.” Staff were aware of their responsibility to safeguard people and who to contact in the event of any safeguarding concerns. One staff member told us, “We would report to the senior or management if someone was being abused.”

The staff received safeguarding training and regular refresher training to ensure they kept their knowledge up to date. Staff were able to describe how they would recognise signs that someone was being abused, and what actions they would take.

The provider was proactive in raising safeguarding concerns with the local authority and CQC. They worked with the relevant professionals to investigate concerns when incidents occurred.

The provider understood their responsibilities under the Mental Capacity Act 2005 in ensuring Deprivation of Liberty safeguards (DoLS) applications were submitted as required. At the time of our inspection, nobody was being deprived of their liberty unlawfully.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Relatives said staff knew their family members’ needs and met these safely. They felt the staff knew how to protect people from avoidable harm.

Risks to people’s health, safety and wellbeing were recorded in their support plans. These contained a section entitled ‘empower, support and facilitate’. This section contained information about person’s health condition and its impact on their life but also included risk and what was in place to reduce this. The risk assessment section was left blank and there was no record of the level of risk before and after interventions to reduce risk. The deputy manager told us they would review and ensure risk was recorded correctly within people’s risk assessments.

There was evidence that measures were put in place to reduce identified risk to people’s health, safety and wellbeing. For example, one person living with dementia could become anxious and distressed and had expressed suicidal thoughts. We saw evidence that appropriate action to prevent the person from experiencing avoidable harm had been taken. This included a referral to the mental health team and 30-minute checks.

Care plans contained detailed information about people’s medical conditions, signs to indicate they were becoming unwell and what actions to take. For example, some people were living with chronic conditions managed by medicines. Care plans provided examples of signs and symptoms to look out for, to help ensure staff would be able to identify a person was becoming unwell.

Incidents and accidents were recorded and contained details such as a description of events leading up to the incident, action and response and a post incident analysis. Each report also highlighted what had been put in place to prevent re-occurrence.

Personal emergency evacuation plans were in place for each person. These contained detailed information about each person and the support they required to safely evacuate the building in the event of a fire or other emergency.

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

People were supported in a safe and well-maintained environment that met their needs. The environment was clean and well adapted for people’s needs. For example, bathrooms were large so they could accommodate wheelchairs.

There were effective systems in place to monitor and regularly check the safety and upkeep of the premises. The management team and staff worked together to help ensure any potential risks were identified and addressed promptly such as faulty equipment or trip hazards.

Safety checks were completed daily and weekly in all areas of the home to ensure safe systems were in place. These included water temperatures, window restrictors, fire safety checks and kitchen equipment.

The provider had an up-to-date emergency plan in place to help ensure people were supported in the event of an emergency or adverse event.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Some people and relatives thought there were not enough staff to meet people’s needs. Their comments included, “There are not always enough staff”, “I would say that there are not enough staff on duty most times”, “Just occasionally there don’t seem to be enough staff. [Family member] has phoned me a few times to say that [they have] been waiting an hour for the loo. We’ve been told a few times that there was an emergency but that’s not right. [Family member] doesn’t like to have an accident”, “Sometimes I feel there aren’t enough staff, especially at weekends, call bells are constant” and “I think at the weekends it’s bad. [Registered manager] says there’s enough but I don’t think so. Sometimes the staff look so tired, sometimes they can be a bit stressed and short with the residents.”

On the day of our inspection, we observed 14 people were left in the bistro area unattended for around 30 minutes. We were told the activity coordinator had asked a member of staff to stay with people, but they had left. This meant there was a risk people’s needs would not be met if they requested support. However, none of these people were assessed as at risk of falls, or at risk to themselves and others. We fed this back to the registered manager who said they would be addressing these concerns.

The provider carried out checks on the suitability of staff before they started working at the service. Systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

Staff told us they were happy working at the home and felt supported and listened to. They said they received training that equipped them to do their job well and care for people who used the service.

Newly recruited staff received an induction which included a welcome and introduction to the different services and people who lived there, health and safety and training the provider identified as mandatory, such as safeguarding, infection control, moving and positioning, communication and health and safety.

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. However, people and relatives’ opinion of the cleanliness of the home varied. One person told us, “The cleaning is not brilliant. There is only one cleaner and [they are] good but there is too much for [them] to do. [They have] around 20 rooms to do so you are probably not getting much more than a lick and a promise. My room doesn’t get done every day” and another said, “Well the cleaning is a bit hit or miss. The bins don’t get emptied every day.” However, others stated, “I’m happy with the cleaning – I’m not sure how often my room is cleaned” and “It is lovely and clean. You would never think that you are in a care home.” This was fed back to the provider.

During our visit, we found the home to be clean and well maintained. Care staff wore appropriate protective personal equipment (PPE) when supporting people to help protect them from cross infection. There were robust cleaning schedules for day and night and staff followed these.

Appropriate systems were in place in relation to infection control. The provider’s infection prevention and control policy was up to date. Information about the risk of infection was shared appropriately with people using the service and visitors. The management team carried out audits to ensure high standards of cleanliness.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines, including controlled medicines, were stored securely and at the appropriate temperatures. There was an adequate stock of prescribed medicines.

Our observations and records we checked showed that people were having their medicines administered as prescribed. For one person after a change in their dosage regime, the staff had failed to put a medicines administration record (MAR) in place. Although the person had not needed this medicine, without a MAR in place this could not be verified. The provider took prompt action and put a MAR in place after we identified this error.

Medicines care plans were in place. These were not always person-centred or did not have the detail to help staff support people with their health needs. For example, there was a lack of clear guidance for staff on how to monitor and manage the side effects of high-risk medicines such as anti-coagulants. For one person living with Parkinson’s, there was no information in their care plan or on the MARs about the specific times to administer these medicines. The provider took prompt action and updated the care plans after this was highlighted during the inspection.

Some people were prescribed medicines to be administered on a when-required basis for health conditions such as constipation and pain. There was guidance in care plans and protocols in place for these medicines to be administered consistently.

Clinical staff from the local GP practice reviewed medicines for people regularly.

There was a medicines policy in place. There was a process in place to report and investigate medicines errors and incidents. Staff carried out medicines management audits to identify gaps and make improvements. The staff received training and were competency assessed to handle medicines safely.