You are here

Archived: Burgess Park Inadequate

The provider of this service changed - see old profile

The provider of this service changed - see new profile

We are carrying out a review of quality at Burgess Park. We will publish a report when our review is complete. Find out more about our inspection reports.

Reports


Inspection carried out on 23 January 2017

During a routine inspection

Burgess Park is a nursing home that provides accommodation and personal care for up to 60 people, some of whom are frail and live with dementia. At the time of the inspection there were 31 people living at the service.

We carried out a comprehensive inspection at this service on 17 December 2015, and rated it as requires improvement. At that time we found two breaches in regulations for safe care and treatment and good governance. We asked the registered provider to send us a plan to tell us what they would do to meet legal requirements. We did not receive the action plan.

We carried out a focussed inspection on the 13 September 2016. We did not look at all of the Key Lines of Enquiry under each key question. We followed up on the breaches of regulations to see if the registered provider had made improvements to the service. At the last inspection on December 2015 we asked the provider to take action to make improvements for safe care and treatment and good governance. We found for safe care and treatment this action has been completed. However, we found the provider was in continued breach of good governance. We also found new breaches of staffing and person centred care. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. You can read the report from our last inspection, by selecting the 'all reports' link for Burgess Park on our website at www.cqc.org.uk.

This comprehensive inspection was carried out on 23 and 31 January 2017 to check that the registered provider had followed their plan and to check that they now met the regulations inspected. During this inspection, we found evidence that the provider had made some improvements. We found that the breach in relation to staffing was now met. We found a continued breach of good governance. We also found new breaches of safe care and treatment and need for consent. We found that further action is required to meet all the regulations we inspected.

There was no 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. The registered provider was recruiting for a home manager. There is an interim manager at Burgess Park supporting the service whilst a permanent manager is recruited.

People did not receive safe care and treatment that met their needs because staff had not acted to manage them. People's health conditions were not managed well and they were at risk from deterioration of their health. Staff had not always followed health care professional’s advice and recommendations to manage people’s health needs effectively.

People did not have their medicines provided to them in a safe way. We found examples where staff did not administer medicines to people a way that helped maintain their health.

The quality assurance systems in place did not identify the areas of concern we found. The provider’s governance systems and audit systems were not always well organised. People did not receive safe quality care because the governance systems did not identify any concerns with the service.

People and their relatives, gave feedback to the provider about the quality of care they received. However, we found that the quality of care experienced did not match our findings at the inspection.

Assessment identified people’s care and support needs. These were completed with people and their relative. A plan of care was developed in order to provide guidance for staff to meet those assessed needs. However we found that reassessments of people’s needs did not take into consideration new health needs. Risks to people’s health and well-being were not always identified and used to plan their care.

Activities for people did not alway

Inspection carried out on 13 September 2016

During an inspection to make sure that the improvements required had been made

This inspection took place on 13 September 2016 and was unannounced. Burgess Park is a nursing home that provides accommodation and personal care for up to 60 people, some of whom are frail and live with dementia. At the time of the inspection there were 41 people living at the service.

There was no 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.

The manager at the service and had made an application to the Care Quality Commission to become the registered manager. During the inspection we were informed that the manager of the service, who had made an application to the CQC to become a registered manager, was supporting a manager at another service three days a week. After the inspection we were informed that the manager of the service had left Burgess Park to become the manager of the other service. We were informed that the deputy manager will be supporting the service in the interim whilst a permanent manager is recruited to the service.

We last inspected this service in December 2015, and rated it as requires improvement. At that time we found two breaches in regulations which included breaches relating to safe care and treatment and good governance. We asked the registered provider to tell us what they would do to meet legal requirements. We did not receive the action plan.

On the 13th September 2016, we carried out a focussed inspection so we did not look at all of the Key Lines of Enquiry under each key question. We followed up on the breaches of regulations to see if the provider had made improvements to the service. At this inspection we found the provider was still in breach in relation to good governance. We also found new breaches in relation to staffing and person centred care.

People did not have sufficient numbers of staff caring for them. During the inspection we saw that there was not enough staff available to support people. We observed that people did not have their basic hygiene needs met and call bells were not answered in a timely manner. Staff we spoke with told us there were not enough staff on duty. The manager of the service did not follow the assessment tool used to assess the level of staff required to meet the needs of people. We are considering our regulator response to this breach of regulation and will report to resolve the problems.

People did not have activities that met their preferences or needs. We observed that one person who did not speak English did not have activities tailored to their needs. We also found that people who were unable to leave their bedroom due to frailty did not have individual social activities as identified in their care records. The service did not develop strong links with the local community to reduce the social isolation of people living in the service.

The quality assurance systems in place were not effective because it did not identify the areas of concern we found. Over the past six inspections at this service since 2013, we have found several breaches of the 2010 and 2014 regulations in all expect one inspection. We found the same or similar breeches in regulations at our inspections during this period where the provider had failed to act on these to improve the care and support people received.

People and their relatives, gave feedback to the provider. Feedback received by the provider showed people reported they were happy with the care and service provided. However this was in contrast to what people told us. Staff provided feedback to the registered provider and they analysed the findings. The regional manager then analysed these which showed staff were satisfied with their job. This was in contrast to what staff told us that there were

Inspection carried out on 17 December 2015

During a routine inspection

This inspection took place on 17 December 2015 and was unannounced. Burgess Park is a nursing home that provides accommodation and personal care for up to 60 people, some of whom are frail and live with dementia. At the time of the inspection there were 32 people using the service.

There was no 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.

The last time we inspected this service in July 2015, they were rated inadequate. A number of breaches in regulations were found. This included breaches relating to person-centred care, need for consent, safe care, and treatment, premises and equipment, good governance, staffing and notification of other incidents.

During this inspection, we found evidence that the provider had made some improvements. The provider had employed a new home manager who had implemented some actions to improve the service. Some of the improvements we found included; person centred care, dignity and respect, need for consent, premises and equipment, staffing and notification of other incidents. However, further action is required to meet all the regulations we inspected.

The provider had safeguarding processes and guidance in place for staff to keep people safe from harm. Staff had an awareness of the signs of abuse and demonstrated how they would raise an allegation of abuse.

People had sufficient staff caring for them. Recruitment processes in place ensured the safe employment of staff to work at the service. Employment checks took place before staff worked with people.

The management of medicines were safe. Medicines were stored safely. There were completed records for the administration of medicines for people. There were processes in place for ordering, disposal, administration, and safe management of people’s medicines.

Staff had received training, supervision, and appraisals to support them in their roles.

People gave staff consent to receive care and support. People had their care managed within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The manager understood their role for caring with people in line with the Deprivation of Liberty Safeguards (DoLS).

People had food and drink that they enjoyed. A menu was available for people to choose meals they liked. People had their nutritional needs met because staff understood and met them.

People had access to health care services when their health needs changed. Staff made referrals to health care professionals for further advice and guidance to manage their health conditions. Staff followed health professional’s guidance and recommendations for people.

Staff treated people with kindness and compassion. We observed examples where staff engaged well with people and their relatives. Staff had made contact with people’s relatives to involve them in making decisions and in the review of their care. People had their dignity and privacy respected by staff.

People contributed to the development of their care. People’s assessment identified their needs and a care plan developed to meet them. Staff had guidance from people’s care plans to ensure that care delivered was appropriate. Assessment were carried out on people’s changing needs were and care delivered was flexible to meet their changing needs. People were involved and contributed to the assessment or review of their care.

People were aware of the process to follow if they wanted to raise a complaint. The majority of people we spoke with said they were happy with the service.

People and their relatives, gave feedback to the provider. The regional manager then analysed these, for areas of improvement a plan developed to improve the service. The majority of people reported they were happy with the care and service provided.

However, we found the provider had not made enough improvements to meet the regulations. There were continued breaches in in relation to safe care and treatment and good governance.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

CQC is considering the appropriate regulatory response to resolve the problems we found in respect of this regulation. We will report on action we have taken in respect of this breach when it is complete.

Staff identified risks to people’s health and well-being. However, we found, risks assessments associated with fire safety did not protect people. The manager had not taken appropriate action to manage fire safety risks at the service. Regular fire assessment and audits of the service took place and the provider identified areas for improvement, however, prompt action to resolve fire safety concerns did not happen. The provider had completed regular monitoring and review of the delivery of the service to ensure care delivered was accurate and met people’s needs. However, they did not identify the areas of risk we found. At the time of the inspection, people who required them did not have appropriate fire evacuation equipment available.

Inspection carried out on 15 and 17 July 2015

During a routine inspection

This inspection took place on 15 and 17 July 2015 and was unannounced. Burgess Park is a nursing home that provides accommodation and personal care for up to 60 people, some of whom are frail and live with dementia. People lived on the first and second floors of the service and the ground floor was closed for refurbishment. At the time of the inspection there were 32 people using the service.

At our previous inspection on 2 March 2015 the service had not met the regulations we inspected. We issued two warning notices, which relate to person-centred care and dignity and respect. We also found other breaches which relate to safe care and treatment, meeting nutritional and hydration needs, good governance and notification of incidents to the Care Quality Commission. We issued three requirement notices for these breaches. We asked the provider to send us a report about how they will improve the service to meet our regulations. The provider sent us the report as requested.

At this inspection we followed up on the outstanding breaches of the regulations. We found that some action had been taken to address one previous breach relating to meeting nutritional and hydration needs. However, we found that the provider had not made sufficient improvements to address all the breaches. There were continued breaches in person-centred care, dignity and respect, safe care and treatment, good governance and notifications of incidents to the Care Quality Commission. We also found new breaches with regards to consent, premises and equipment, and staffing.

At this inspection we found eight breaches of regulations for person-centred care, dignity and respect, need for consent, safe care and treatment, premises and equipment, good governance, staffing and notifications of incidents to the Care Quality Commission.

There was no registered manager in post as at the time of our inspection. 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. There was a peripatetic manager in post managing the service. They told us since our previous inspection on 2 March 2015, the registered manager had left the service and a new manager had been recruited. The newly appointed manager was not yet working at the service and therefore not present at the inspection.

Incidents and accidents which occurred at the service were not always recorded. The provider had not correctly assessed the level of staffing required to meet people’s needs.

Medicines were not managed safely. People did not always receive their medicines in line with the prescriber’s instructions. People were also at risk of infection because safe standards of cleanliness were not always maintained.

Whilst staff received regular training and supervision to support them in their caring role, they did not have regular appraisals. The manager was not aware of their responsibilities within the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People and their relatives were not always involved in discussions or in assessments about their mental capacity.

People’s interests, social or cultural needs were not met by the activities provided. Staff were unaware of people’s cultural needs and personal histories. The provider had not supported people to access local community groups or advocacy services which could provide help and support to them. People were not always provided with meals which met their needs because they were not offered any choice in their meals.

People or their relatives were not involved in making decisions regarding their care needs. People’s assessments, daily observation charts and care plans were not regularly updated. The provider monitored the service and carried out quality audits; however these did not always identify areas of concern or make improvements, so that people received consistent quality of care.

People and their relatives told us they were treated with dignity and respect by staff. However, this did not reflect our observations during the inspection.

People and their relatives were asked for their opinions on the quality of the service and some of these were acted on. People were provided with information on how they could make a complaint and how the complaint would be managed.

Staff were aware of the signs of abuse and how to report an incident of abuse to their line manager or peripatetic manager of the service.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special measures'.

The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 2 March 2015

During a routine inspection

The inspection took place on 2 March 2015 and was unannounced. At the time of the inspection there were 41 people using the service, who were older people some with dementia.

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.

At the last inspection on 12 November 2014 the service was meeting the regulations we inspected.

The provider was in breach of eight regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During this inspection we found a number of breaches. Assessments and care plans were not regularly reviewed and updated to reflect changing need for a person. Professional recommendations made to manage risk were not always acted on by staff, increasing risk to people’s health and wellbeing.

People did not always receive food which met their health and cultural needs. A food quality audit completed in February 2015; found people were unhappy with the availability and quality of food. The registered manager and interim manager had not taken action on people’s comments by improving the quality of food provided for them.

There were two current staff duty rotas in use. One staff rota had details of staff scheduled to work. The other staff rota held details of staff that were scheduled to work on each shift and had information on staff sickness, absence and agency staff used. The regional manager, interim manager and the deputy manager were unable to tell us how many staff were on duty; they provided us with three different numbers of staff. People did not always receive care promptly, because staff were not available to assist them.

People were not always treated with dignity and respect by staff.

People and their relatives were asked for feedback on the quality of the service; however, their responses were not acted on by the registered manager or interim manager.

Incidents and accidents were recorded and a report produced of these. The interim manager had not provided staff with guidance on how to reduce the risk of an accident or incident recurring. People were not kept safe.

Medicines were not managed safely. People did not always receive their medicines at the prescribed times or following the prescriber’s instructions.

Staff were aware of the signs of abuse and were able to tell us how they would escalate an allegation of abuse.

People were provided with information on how they could make a complaint and how the complaint would be managed.

Senior staff provided training, supervision and an appraisal for staff. Newly employed staff completed an induction programme so they could develop their skills and knowledge in order to meet the needs of people they cared for.

Staff were aware of their responsibilities within the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Some people and their relatives were involved in assessments to determine their ability to consent to care and support.

People were at risk of receiving poor care and support. People did not take account of their comments or acted on them to improve the quality of the service they received. People did not receive medicines in a safe way. The provider did not provide food and nutritional support which met their cultural or medical needs. Staff did not always treat people with dignity and respect. The provider did not send us notifications of safeguarding allegations. People’s records were not updated to reflect the needs and support people required and the provider did not have sufficient staff to care for the needs of people living at the service.

We are taking action against the provider for breaches of the regulations in relation to; care and welfare of service users (Regulation 9), assessing and monitoring the quality of service provision (Regulation 10), safe care and treatment (Regulation 12), management of medicines (Regulation 13), meeting nutritional needs (Regulation 14), good governance (Regulation 17), staffing (Regulation 18) and notification of other incidents (Regulation 22A (CQC Registration)).

We will report on it when our action is completed.

Inspection carried out on 12 November 2014

During an inspection to make sure that the improvements required had been made

One inspector, a specialist advisor and an expert by experience carried out this follow up inspection. During our visit we gathered evidence to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Is the service caring?

People were supported by knowledgeable staff who knew the health and care needs of people they cared for. Staff engaged well with people and provided them with opportunities to participate in social activities. People were treated with respect, dignity and kindness.

Is the service responsive?

People or their relatives told us they were asked for their views of the services. Relatives had regular meetings with the registered manager. Some relatives said that senior staff took notice of what they told the manager. An example given was that a request was made for the registered manger to invite senior managers to the residents and relatives meetings. Minutes from these meetings were displayed on the notice board with actions taken.

Is the service safe?

Staff were aware of how to care for people with complex health needs. We saw that staff made referrals for specialist advice if required. For example, to the physiotherapist, GP or tissue viability nurse. Where people required support from two carers, this was provided for people.

Is the service effective?

People had an assessment of their needs before living at the service. Assessments were thorough to establish whether people's health and social care needs could be met at the service. Risks assessments and management plans were developed and implemented to reduce risks.

Is the service well led?

People’s personal records including medical records were accurate and fit for purpose. People had regular monthly reviews; copies of the reviews were held on their care records. We found that the registered manager had made notifications to the CQC, appropriately. We were able to track each notification sent with an outcome.

Inspection carried out on 4 June 2014

During a routine inspection

One inspector carried out this inspection at Burgess Park. During the inspection, the inspector gathered information to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Is the service safe?

We looked at six people’s care records and saw that the service had plans in place to manage risks to their health. For example, there was guidance on how to support people who were at risk of developing pressure ulcers. However, staff had not always fully implemented these plans. We found that staff did not always protect people from risks identified from an assessment. For example we observed one person was not supported with daily transfers out of bed.

Two relatives told us that staffing levels were low at the home and it was sometimes difficult to get the attention of care staff. Following change in management a number of staff had left Burgess Park, and ten newly appointed staff were being inducted into the home.

On our inspection there was one nurse on night shift, due to staff absence. We looked at the nurse’s rota and saw that two nurses should be on night duty. However, the manager provided staff to cover this absence.

People were at risk of receiving unsafe care because risk management plans were not always been put into action.

Procedures for dealing with emergencies were in place and staff were able to describe these to us.

The provider and staff understood their responsibilities under the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS).

Is the service effective?

People had an assessment of their needs before receiving care and support; from this information, individual care plans and an assessment of risk were developed. Assessments included needs for any equipment, mobility aids and specialist dietary requirements. Care plans identified areas of risk and a management plan was developed to minimise them. However, we found that staff did not always implement professional guidance.

Is the service caring?

People told us that staff were kind, supportive and staff were aware of their individual needs and preferences. We observed staff did not always treat people with respect and dignity. We observed one member of staff shouting at a person using the service and another member of staff addressing people as “sweetheart”, “love” and “darling”. Staff did not always engage well with people or offer choices; for example we saw a member of staff turn on the radio while people were having breakfast, people were not asked if they wanted the radio on or what radio station they wanted to listen to.

Is the service responsive?

We saw that the provider made arrangements for people with additional health and social care support needs when required. We saw that referrals had been made to health professionals, including GP, tissue viability nurse and speech and language therapist (SALT) for people, meeting their changing care needs.

Staff took action when appropriate to cater to specific needs of people, for example a recommendation was made for an individualised activities plan for one person. We saw that staff implemented this recommendation and we saw that staff engaged the person in activities on a daily basis.

Is the service well led?

People told us they felt able to raise and discuss concerns with staff or the manager as appropriate. Some staff told us they felt supported and listened to by the manager of the service. They said the manager was responsive to any requests and they felt involved in decisions about the care provided to people they supported. Regular team meetings were held and people were encouraged to raise any concerns or issues, and recorded in the team meeting minutes.

There was a residents meeting held with staff, people and relatives of people using the service. People raised issues and a record of the meeting minutes were provided to people. A response to the issues raised and appropriate actions taken by the manager were documented.

Staff received training regularly and new staff completed their induction, all mandatory training was up to date and staff received regular supervision and had an appraisal in place. We reviewed four staff records and we saw that the provider’s recruitment process had been followed. We saw documents held on staff records regarding; recruitment and interview process, references, identification, Disclosure and Barring Service (DBS) checks or Criminal Records checks (CRB), as appropriate.

Inspection carried out on 19 August 2013

During a routine inspection

During this inspection we checked to see whether areas of concern previously identified on 15 March 2013 had been addressed. We found that much improvement had been made but there was still some improvement required.

People had appropriate care plans in place and regular review of risks to ensure there was up to date information about how they were to be cared for and supported. For the majority we found that the care provided was in line with that outlined in their care plans. However we found that further improvement was required regarding protecting people from the risk of developing pressure ulcers.

We observed that people had good access to food and drinks throughout the day. The chef was knowledgeable on people’s individual dietary requirements.

The service was visually clean and we found that staff were knowledgeable in how to reduce the risk and spread of infections.

People using the service told us they liked the staff and the staff were aware of how to meet their needs. However, we found that at times the service was short staffed which meant that people had to wait for their needs to be met.

A new supervision and induction process had been introduced to support staff. However, we found that not all staff were up to date with mandatory training. This meant there was a risk that staff were not skilled or knowledgeable on how to support people using the service.

Inspection carried out on 15 March 2013

During an inspection in response to concerns

During our inspection we looked at eight care records and spoke with four people using the service. We also spoke with eight staff members.

The majority of people had appropriate care plans and risk assessments in place. However, at times appropriate pressure sore prevention measures were not in place, which meant that some people were at risk of developing pressure sores.

Some people were not receiving appropriate amount of foods and fluids, and we saw that some people were not woken up to eat and drink which meant they went a long time without food or drink. We saw that fluid charts were not consistently used to monitor the intake and output of fluids and people were regularly not drinking the recommended amounts of daily fluids, which meant they were at risk of dehydration.

We found there were not enough qualified, skilled and experienced staff to meet people’s needs. Staff at the service were very busy and told us they were not able to meet the needs of people using the service. We observed that sometimes when people used their call bells or called out to staff for help they had to wait for assistance as there were times when no staff were available to assist them, because they were busy supporting other people.

Inspection carried out on 9 January 2013

During a routine inspection

During the inspection we spoke with seven people that used the service, six staff members and reviewed five sets of care records.

People told us that they felt well informed and involved in decisions about their care and treatment. Their preferences over food choice, bed times and personal care were respected, and observations showed staff treated them with respect and protected their dignity and privacy.

Care records were up to date and evidenced comprehensive assessment and care planning. People’s physical, emotional and social needs were addressed and care plans were developed in discussion with people who use the service. One person told us “the staff talk to me about what they can do for me but I like to just get on with things and they let me.”

There were appropriate processes for management of medicines. The medication administration record (MAR) charts were completed correctly and observations on the day showed safe administration of medication.

Effective recruitment and selection processes were in place, with accurate pre-employment checks being carried out.

Effective quality checking systems were in place and there was regular monitoring of the quality of service provision through audits and staff meetings. People who use the service were able to feedback about the service through regular 'residents' meetings.

Inspection carried out on 18 January 2012

During an inspection to make sure that the improvements required had been made

People who live at the home said that they are happy there and that they are provided with good care. One person said that she was welcomed to the home when she came to stay and feels very settled. People said that they were happy with the service but if they had concerns they felt able to raise them.

Staff said that the staffing levels have increased since Four Seasons Health Care has been managing the service. Staff said that they are well supported and there are good training opportunities available to them. They said that staff morale has improved in recent months.

There has been significant improvement in the service provided since our last visit to Burgess Park.

Inspection carried out on 28 September 2011

During a routine inspection

People told us that they are happy with the service and that they receive the care they require.

One person told us that their relative had been well cared for in the home for several years but unfortunately their needs had changed. Referrals were made by staff for reassessment and she was due to transfer to a home with facilities appropriate for people with mental frailty.

Another visitor said that their relative has done well since they came to live at Burgess Park saying that the person ‘eats well, sleeps well and is happy’.

People said that they liked the meals. Some people, who have special dietary needs, arising from their culture or health, said that they did not always receive appropriate meals.

People said that the staff were kind and helpful. We were told that the staff were respectful of people, including their individual views and beliefs.