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Archived: Burnham Requires improvement

The provider of this service changed - see old profile

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 January 2018

The inspection took place on 30 November 2017. The inspection was unannounced.

At the previous inspection on 19 April 2016 when the provider and service was registered as a different legal entity. There was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. This related to records missing from staff recruitment files within the safe domain.

After the inspection the provider sent us an action plan on 16 June 2016 which detailed how they planned to address the breach of Regulations. The action plan stated they had met the Regulation by May 2016.

Burnham is a care home providing accommodation and personal care for up to five people with physical disabilities. 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. At the time of our inspection five people lived at the service. Three people lived on the ground floor and two people lived on the top floor which was accessible to them because a through floor passenger lift was fitted.

The service had a registered manager. 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 this inspection people told us they enjoyed living at the service. They got on well with staff and we saw that people were comfortable and relaxed.

The provider had not always followed effective recruitment procedures to check that potential staff employed were of good character and had the skills and experience needed to carry out their roles.

The service had not been adapted to ensure all areas had wheelchair access, which meant people were unable to access to kitchen. We made a recommendation about this.

Effective systems were not in place to enable the provider to assess, monitor and improve the quality and safety of the service. Records were not always complete, accurate or securely stored.

People's care plans detailed most of their care and support needs. However, care plans did not all reflect each person's current need or specific healthcare needs.

Appropriate numbers of staff had been deployed to meet people's needs. Staff had attended training relevant to people's needs and they had received effective supervision from the registered manager.

Risk assessments were in place to mitigate the risk of harm to people and staff. Medicines had been well-managed.

People were provided with meaningful activities to promote their wellbeing. People accessed their local community both with their relatives and with the staff.

People had choices of food at each meal time. People had adequate fluids to keep themselves hydrated. A person received their fluid and food through percutaneous endoscopic gastrostomy (PEG), they received the correct amount of meals as detailed by specialists to keep them healthy.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People were not deprived of their liberty, so not applications had been made.

Staff knew and understood how to protect people from abuse and harm and keep them safe.

People were supported and helped to maintain their health and to access health services when they needed them.

Maintenance of the premises had been routinely undertaken and records about it were complete. Fire safety tests had been carried out and fire equipment safety-checked.

Staff were cheerful, kind and patient in their approach and had a good rapport with people. The atmosphere in the service was calm and relaxed. Staff treated people with dignity and respect.

People were supported to maintain their rel

Inspection areas


Requires improvement

Updated 10 January 2018

The service was not consistently safe.

The provider had not always followed safe recruitment practices.

Potential risks to people and staff were identified and action taken to minimise their impact.

Medicines were managed safely. People received their prescribed medicines at the right times. Lessons had been learnt and practice had improved when things had gone wrong.

Staff knew how to recognise any potential abuse and so help keep people safe.

There were enough staff available to meet people�s needs.

The service was clean and practices were in place to minimise the spread of any infection. The service was well maintained.


Requires improvement

Updated 10 January 2018

The service was not consistently effective.

The service had not been adapted to ensure all areas had wheelchair access. Not everyone could access the kitchen.

Staff had received training relevant to their roles. Staff had received supervision and good support from the management team.

People had choices of food at each meal time which met their likes, needs and expectations. One person received their food and drink through a specialist feeding tube. The records relating to food and drink given through the tube had not been adequately recorded.

Staff had a good understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. People were supported to make choices about all elements of their lives.

People received medical assistance from healthcare professionals when they needed it.



Updated 10 January 2018

The service was caring.

People were treated with dignity and respect.

People were involved with their care. Peoples care and treatment was person centred.

People were able to contact their relatives when they wanted to and were supported to maintain contact with their relatives. Relatives were able to visit their family members at any time.


Requires improvement

Updated 10 January 2018

The service was not consistently responsive.

Care plans were in place, these were person centred. Care plans were not in place for all people's known and assessed needs. Some people�s care records evidenced that advanced care planning had taken place to record their wishes and preferences around the end of their lives.

People we spoke with knew how to complain. Complaints information was on display in the service.

Activities were taking place to ensure people could keep active and stimulated when they wanted to be, both in the service and the local community.


Requires improvement

Updated 10 January 2018

The service was not consistently well led.

Audits had not always been totally effective in identifying shortfalls in the service. Additional improvements to policies, procedures and practice were identified. The registered manager planned to report this to the provider.

Records had not always been stored correctly to maintain confidentiality.

The registered manager had reported incidents to CQC. The provider had displayed the rating from the last inspection in the service.

Staff were aware of the whistleblowing procedures and were confident that poor practice would be reported appropriately.

People and staff felt the registered manager was approachable and would listen to any concerns. Staff felt well supported by the management team.