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Burnham Lodge Nursing Home Requires improvement

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 11 April 2018

This inspection took place on 6 and 7 March 2018 and was unannounced.

We last undertook a comprehensive inspection at Burnham Lodge Nursing Home in August 2017. At this inspection in August 2017 we found the provider to be in breach five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Regulation 9, Person centred care, Regulation 11, Need for consent, Regulation 12, Safe care and treatment, Regulation 15, Premises and equipment, and Regulation 17, Good governance.

Following the inspection in August 2017, we served two Warning Notices for breaches in Regulations 12 and 17. In addition to this, we set requirement actions relating to breaches 9,12, and 15. We also asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective, caring, responsive and well led to at least good. The provider told us they would make the required improvements by January 2018.

We undertook a focused inspection in December 2017 to check the provider was meeting the legal requirements for the two regulations they had breached that resulted in them being served Warning Notices. During the focused inspection we found the provider had taken action to ensure compliance with these regulations.

During this comprehensive inspection in March 2018 we found improvements had been made in some areas, we also found areas that still required improvement.

Burnham Lodge Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Burnham Lodge Nursing Home provides residential and nursing care for up to a maximum 23 people. At the time of our inspection, 19 people were living at the home. The home specialises in caring for older people including those with physical disabilities, people living with dementia or those who require end of life care.

There was a registered manager in post. 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.’

People told us they were happy with the food provided. Our observations of the mealtime experience were mixed, some improvements were required to ensure people had a choice of the meals provided.

Some improvements were still required to ensure people’s rights were fully protected in line with the Mental Capacity Act 2005.

Our observations of people’s involvement in meaningful engagement was mixed; the registered manager had plans in place to improve this. Care plans still required further information to ensure they identified people’s social, spiritual and wellbeing needs.

There were systems in place to assess, monitor and improve the quality and safety of the service provided. These systems were identifying where some improvements were required, however they did not identify all of the shortfalls we found. During this inspection we found some similar concerns to our previous comprehensive inspection.

People felt safe living at Burnham Lodge Nursing Home. People were supported by staff who knew how to recognise and report abuse. Recruitment procedures were in place to ensure staff employed were suitable for their role.

Where risks had been identified to people’s safety, suitable measures were in place to reduce the identified risks. Staff were aware of people’s risk assessments and guidelines.

Staff were recording incidents when they occurred, these were reviewed by the registered manager for any lessons to be learned.

Medicines were administered safely to people, and people were happy with how staff administered their medicines. Some improvements were required with recording of medicines that were applied topically to the skin.

We received mixed comments from people about the staffing levels in the home, our observations were that there were enough staff available to meet people’s needs.

The home was clean and free of odours. There were systems in place to ensure people were protected from the risk of the spread of infection

Staff monitored people’s health and well-being and made sure they had access to healthcare professionals according to their individual needs.

Staff told us they received supervision and felt supported in their role. Staff received a range of training to help them to meet people’s needs.

People were supported by staff who were kind and caring. Staff treated people with respect and dignity.

People felt able to raise concerns with staff and the registered manager. Staff felt well supported by the registered manager and felt there was an open door policy to raise concerns.

There were systems in place to share information and seek people's and relatives views about the care and the running of the home.

We have made a recommendation about the service reviewing how the service support people in line with the Mental Capacity Act 2005.

Inspection areas

Safe

Good

Updated 11 April 2018

The service was safe.

People’s medicines were stored and administered safely. Some records of medicines that were applied to the skin were not consistently completed.

Risk’s to people’s safety were assessed and planned for.

People were supported by staff who knew how to recognise and report abuse.

Systems were in place to minimise the risk of infection.

There were sufficient staff available to meet people’s assessed care and support needs.

Lessons were learnt and improvements were made when things went wrong.

Effective

Requires improvement

Updated 11 April 2018

Some aspects of the service were not fully effective.

Some improvements were required to ensure people’s rights were fully protected in line with the Mental Capacity Act 2005.

People’s mealtime experience was mixed.

People were supported by staff who received training relevant to their role.

People were supported by staff who felt supported in their role.

People’s healthcare needs were supported and met.

There were plans in place to ensure the premises fully met people’s needs.

Caring

Good

Updated 11 April 2018

The service was caring.

People were treated with dignity and respect.

People were supported in line with their preferences.

People were supported by staff that treated them with kindness, respect and compassion.

Responsive

Requires improvement

Updated 11 April 2018

The service was not fully responsive.

Improvements were required to ensure people’s social, spiritual and wellbeing needs were fully assessed and planned for.

People’s care needs were assessed and planned for.

A complaints procedure was in place. People and their relatives told us they felt able to raise concerns with the staff and management.

People’s choices and preferences around the care they wished to receive at the end of their life was discussed and recorded.

Well-led

Requires improvement

Updated 11 April 2018

The service was not always well led.

The systems in place to monitor and improve the quality of the service for people were still not fully effective.

People were supported by staff who felt able to approach their managers.

There were systems in place to ensure people and their relatives had an opportunity to provide feedback on the service.