• Care Home
  • Care home

Burrswood Care Home

Overall: Inadequate read more about inspection ratings

Newton Street, Bury, Lancashire, BL9 5HB (0161) 761 7526

Provided and run by:
Advinia Care Homes Limited

Latest inspection summary

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Background to this inspection

Updated 21 October 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Inspection team

The inspection was carried out by 3 inspectors, 2 medicines inspectors and specialist nurse advisor.

Service and service type

Burrswood is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Burrswood is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with CQC to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post. However, in the days following the inspection they had resigned. An interim home manager was then brought in to oversee day-to-day operational management.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We also contacted the local Healthwatch team. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 8 residents and 5 visiting relatives to understand their experiences. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with the registered manager, deputy manager, divisional director, 4 registered nurses, unit managers, 3 seniors, 8 care assistants, administration staff, domestics and catering staff.

We looked at medicines and records about medicines for 25 people, 10 electronic care plans and associated records, training records and information related to safety, audit and quality assurance.

Overall inspection

Inadequate

Updated 21 October 2023

About the service

Burrswood Care Home, owned and operated by Advinia Care Homes Limited, is registered with the Care Quality Commission (CQC) to provide personal and nursing care to a maximum of 125 people. 75 people were accommodated at the time of inspection.

Accommodation is divided across 3 separate units. These are described by the provider as Peel (providing nursing care to people living with dementia) Kay (providing residential care to people living with dementia) and Crompton (providing general residential care). A fourth unit, Dunster, had previously provided general nursing care but had recently closed

People’s experience of using this service and what we found

Medicines were not managed safely which placed people at risk of harm. Medicines could not always be accounted for, which meant these medicines may not have been given as prescribed or misused; it was of particular concern that there was less stock of some medicines which can cause people to be drowsy than expected. Medicines that needed to be taken at specific times were not given safely. Some people were given their night time medicines at teatime on 3 days because there were no staff trained to give medicines working on that unit on those nights.

Management of witnessed and unwitnessed incidents, including falls, was not safe. We found multiple examples where people were known to be at risk, but there had been a failure to act to adequately mitigate those risks. Safeguarding referrals had not always been made to the local authority safeguarding team where people had experienced harm. Deployment of staff was disorganised and frequently chaotic. This was most evident on Peel unit where we found a distinct lack of leadership and management. Staff worked to a ‘task-and-time’ regime which meant daily routines were operated for the convenience of staff, and not in a person-centred way to best support people.

The food and drink offer across the home was poor. Choice was limited and food was not always nutritious. The needs of people who required a modified diet due to a medical need were not always met. Some people had food preferences based on their religious or cultural background. However, these preferences had been flagrantly ignored by staff.

Induction, training and development of staff was inadequate. There was a distinct lack of qualified nursing staff with the relevant professional training, skills, and experience to effectively deliver nursing care to people living with complex advanced dementia. People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. The environment, décor and design of the home was not in line with national best practice guidance for supporting people living with dementia.

Whilst it was evident some staff were caring and well intentioned, for others, they appeared indifferent and disinterested. Too often we observed staff not paying attention to basic matters of dignity, privacy and compassion. The individuality and diversity of people receiving care and support was not acknowledged or celebrated in any meaningful way. This was particularly concerning for those people who may have protected characteristics.

The provision of activities and opportunities for people to follow their interests was woefully inadequate. There was too much of an inward focus and links with the local community were virtually non-existent.

There had been a systemic failure of leadership and management across all areas. There was a deep sense of mistrust between staff, the registered manager, deputy manager and senior managers acting for the provider. This led to a closed toxic culture amongst staff which led to poor quality care. There were significant failures in governance, audit, quality assurance and questioning of practice. Governance systems were not operated effectively and were not fit for purpose.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 06 September 2022).

Why we inspected

This inspection was planned in response to emerging risk based on information of concern received from relatives, intelligence from local stakeholders, and our own analysis risk. Key themes centred on pressure wound care, staffing levels, management of falls/unwitnessed events and leadership and management.

Enforcement and Follow up

We have identified breaches of legal requirements in respect of safe care and treatment, protecting people from abuse and improper treatment, staffing, person-centred care, meeting nutritional needs, dignity and respect, and good governance.

The overall rating for this service is ‘Inadequate’ and the service is therefore placed in ‘special measures’. Full information about CQC’s regulatory response to the serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We are currently keeping the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

In the intervening period between our inspection visits and publication of this report, CQC have worked closely with partners from the local authority, NHS and police to ensure the health, safety and wellbeing of people. This activity remains ongoing at the time of this report.