Burlington Mews 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.

Staff were trained and skilled to provide safe care. Regular handovers and staff meetings ensured knowledge and experiences were shared. Incidents and accidents were recorded with investigation meetings to learn from. The provider evidenced that, when concerns arose, they were actioned and dealt with quickly and efficiently. This ensured that people were not in discomfort or at risk of avoidable harm.

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 nominated individual explained how the service worked with appropriate healthcare professionals to ensure safe and effective care. Records evidenced the service had good working relationships with health and social care professionals. This included GP’s, care agencies and district nurses to ensure that information was available when moving between services to ensure a smooth transition process.

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.

The nominated individual ensured any concerns were raised with the local authority safeguarding team and the CQC. The provider had safeguarding and whistleblowing policies in place and staff had safeguarding training. Regular audits were completed where different staff members were chosen to test their knowledge to ensure learning was retained. The service ensured families were kept informed when an incident happened. A family member told us, “[person] had a fall, but they rang me and kept me informed and reassured me that they will check on him throughout the day.”

The provider 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.

The provider ensured risk assessments were in place with accordance to people’s needs. However, there was a lack of oversight in the day to day running of the home which could potentially put people at risk of harm. Feedback gathered from relatives stated that they, at times, completed tasks when visiting, such as cleaning and personal care due to a lack of staffing. We observed an incident involving people nearly having a physical altercation where there was no staff member present in the communal lounge and a relative had to intervene.We raised these concerns with the deputy manager on shift who advised that usually there would be a member of staff in the communal lounge but were short staffed on the day.

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 home was well designed to enable people to move about safely. The home was kept clutter free so that people could walk the corridors and a large garden which people could enjoy. The main communal area was consistently in use by people and taking part in activities when they were available. Maintenance audits ensured that relevant safety checks were completed. Management ensured staff had fire training to safely evacuate people in the event of a fire.

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 numbers overall were maintained, however there were not always enough staff on duty for each shift. The provider had ensured that continuous recruitment was in place, but this was due to difficulty with retaining staff. Staff reported a lack of support by management in areas where they were unconfident. A staff member said, “Don't get me wrong, I think people are safe, but we are doing the minimum, we're not providing quality care like we all want to”. The service used a dependency tool to calculate how many staff members should be on shift; however this was not always attainable. A person told us, “Staff are good, but the home could benefit from one or two more staff.” Staff had been recruited safely. Staff files contained the required documents and checks for example, references, photographic identification and Disclosure and Barring Service (DBS) records. DBS checks support managers to make safe recruitment decisions.

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.

Processes were in place to minimise risk and spread of infection. Staff were observed to appropriately wear personal protective equipment (PPE). Staff had training in infection control. Competency checks were completed by leaders on a regular basis. Cleaning schedules were in place to help ensure the home was cleaned and the nominated individual had good oversight of these. The premises were visibly clean the time of our assessment.

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

Medicines were not always safely managed. Staff reported feeling unconfident with medication rounds due to being distracted. For example, a staff member spoke of being taken away from completing the medication round to support people due to the lack of staffing on the day. This increased the risk of medication errors which could cause harm to people. A staff member said, “I only had a little bit of medicines training.” We identified gaps of knowledge in medication management. Discrepancies were identified when recording medication on the electronic system which went against the provider’s medication policy. We observed a plate unsupervised in a hallway that had medication on which someone could have taken. This was addressed with the nominated individual that advised that it would be investigated and reminded staff to vigilant when administering medication. Electronic Medication Administration Records (EMAR) were reviewed and shown discrepancies with medication being ordered in time.