Burnham

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

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. Fire safety risks had not been well managed, fire drills had not taken place and weekly fire alarm testing was intermittent. This was a breach of the regulation concerning safe care and treatment. Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff knew people well and were able to identify changes to health and identify care and support needs. We could not be assured that people benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. This was because there was no record of the analysis and actions. Medicines were administered safely. Medicines stock did not always balance with records. Staff were not always recruited safely, the human resources team took action to resolve this during the assessment. The provider’s systems to ensure appropriate numbers of suitably trained and skilled staff were deployed on shift was not robust. This evidenced that the legal requirement in relation to staffing had not been met. There was a plan in place to make sure staff had ongoing support in the form of supervision and appraisal meetings. The provider worked with people and partners, including local authority care managers and health professionals, to establish and maintain safe systems of care. The provider had systems and processes in place to detect and control potential risks in the care environment and processes in place to assess and manage the risk of infection.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We could not be assured that people benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. This is because there was no record of the analysis and actions. Relatives told us they were kept well informed when there were incidents, changes or concerns. A relative said, “They told me the day it [accident] happened and kept me up to date when they had information.” However, relatives told us they were initially informed of an incident in the summer concerning the whole service and had not been kept up to date since this. The provider had not met with them to discuss this as they had planned to. The provider made contact with relatives to notify them that CQC were assessing the service and arranged a meeting with relatives.

Some staff told us that improvements had been made following accidents and incidents. A staff member told us, “There has been no review or discussions when these [accidents] have happened. I have had a 1:1 where I have asked for a general staff meeting.” Another staff member said, “Prior to the management change there were no lessons learned from incidents and falls, since the change there has been a review re [person’s] mobility.”

Accidents and incidents were recorded, and appropriate actions taken. However, it was not always clear that learning from accidents and incidents had been embedded as care plans and risk assessments had not been updated and reviewed following incidents and accidents.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. A person told us, “If I am unwell, staff call the doctor.”

The management team explained that they worked with others to resolve problems and make improvements. The service had maintained regular contact with local authority social workers. This included good ongoing work with the GP and community nurses and the Home Enteral Nutrition Team and other health and social care professionals. Staff told us they were able to contact the GP and community nurses. A staff member said, “I find speaking to the GP very helpful.”

A health care professional told us, “A staff member is always present and supported [the person with the appointment] when we have visited” and “Care home would call and request a home visit in a timely manner if they felt patients needed to be reviewed.”

The provider worked with people and partners including local authority care managers and health professionals to establish and maintain safe systems of care. Safety was managed, monitored and assured. When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visit, support was in place as well as hospital passports. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital.

People were safe and were protected from harm. People told us, “I feel safe, the front door is locked, I have my own key” and “There is not 1 person that works here that I don’t trust with my life.” A relative said, “I know [person] is happy and safe. She would say if she was not.” Staff were attentive to people’s needs and made sure they were safe as they carried out their daily routines.

Staff had received adult safeguarding training. Staff told us safeguarding training had not included safeguarding children. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed. A staff member said, “I have done safeguarding training. I would take a picture of any injury and report it to the manager. It would be acted on, definitely. Whistleblowing information is on the board in the staff room. I could also report it at [provider’s other local home] to the manager there.” Another staff member told us, “I would take it to [manager] and would report it higher, they are very approachable, I could contact CQC or the county council.”

We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Most people required physical support to move around the service.

Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Safeguarding policies included information about safeguarding children from abuse. Safeguarding training did not include safeguarding children. Staff in care services should receive safeguarding children training as they come into contact with children as part of their work. This meant that staff did not have all the information they needed to work safely. Safeguarding concerns had not always been reported appropriately. The provider had investigated this and taken appropriate action. The management team had reviewed processes and learnt lessons from safeguarding incidents. We checked whether the service was working within the principles of the Mental Capacity Act (MCA), whether appropriate legal authorisations were in place when needed to deprive a person of their liberty. The service worked within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. When people were assessed as lacking capacity to make decisions appropriate procedures were followed to ensure principles within the MCA were followed. Deprivation of Liberty Safeguards (DoLS) applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. Systems to review these were also in place.

People gave us positive views about how staff managed risks well. The service used equipment to help maintain people’s safety. A person told us, “I feel safe. People are prepared to let me go out. They take me out in my wheelchair.”

Staff knew people well and were confident they could identify any changes in people’s presentation that may be of concern. A staff member told us, “Risk assessments are in [electronic care planning system]. When new staff start, they do shadowing and read care plans.”

We observed that risks were not always well managed. Some people’s air mattresses need to be set in line with manufacturer’s instructions and based on people’s individual weights. Checks on mattress settings had not been recorded. When we checked if people’s beds were at the correct setting for their weights, we found one person’s setting had been knocked and was just outside the correct setting. The staff member immediately changed it to the correct setting. They told us bed setting checks were not recorded. The person was not impacted by this and staff reported that their skin was intact. People were supported to move around the service safely and were supported to spend time where they chose. People were given food and fluid in a consistency which was in accordance with their assessed needs (including diabetic diets and nil by mouth). The food was well presented, and people seemed to be enjoying the experience.

Risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. We identified some concerns with pressure area care and support. Several people were at risk of skin breakdown; a person’s skin had developed a sore. The service had requested help and advice from the GP surgery in relation to this sore. However, the risk assessment and care plan had not been updated to reflect the change in the person’s health and change of needs. Risk assessments did not specify what settings people’s air flow mattresses should be on and there were no records of checks made to show that staff were checking that the mattresses were working and at the correct setting, this put people at risk of harm. Some people were at risk of falls. A care plan was in place but this had not been updated to show there had been frequent falls, the falls risk assessment was not person centred. Several people had epilepsy. A person did not have a care plan or risk assessment in place to detail what staff should do if they had a seizure.

People told us that decorating had taken place. A person told us they had been involved in choosing the colours of the paint in their room. They also said their flooring had been deep cleaned.

Staff told us they had not had fire drills to practice evacuation in the event of an emergency and that fire safety had not been prioritised. Staff said, “I have not had a fire drill in 12 months. We did have evacuation beds but not anymore. [Previous registered manager] told us we would have to leave people in their rooms. She said fire doors would give people 30 minutes” and “Room 2 emergency light is still not fixed and this has been a long standing issue.”

People benefitted from an environment that was well maintained and clean. However, we observed from the provider's records that fire alarms had not been tested as regularly as required. We observed that radiators were covered and people had access to fans to cool them down if they required them. There were window restrictors in place to prevent injuries from falls from height. We observed staff carrying out cleaning tasks and emptying bins throughout the service.

Fire safety risks had not been well managed. Weekly fire alarm tests had not been taking place on a weekly basis, records showed staff had not completed fire drills. The management team told us fire alarm tests hadn’t been completed when the maintenance team were unavailable and arrangements were not in place to make sure they were completed by other staff. Records also showed that emergency lighting in one area of the service was not working. We reported our concerns to Kent Fire and Rescue. The fire policy for the service had not been updated with new information when management arrangements had changed, this meant staff did not have clear instructions on what to do. The provider had systems and processes in place to detect and control other potential risks in the care environment. This made sure that the equipment, facilities and technology supported the delivery of safe care. Essential servicing and maintenance of the gas, electric, lift, fire alarm system, emergency lights, moving and handling equipment had taken place. The fire alarm was scheduled to be replaced in November 2024.

People gave us positive views about whether there were enough staff on duty at the service. People said, “I can call staff using my buzzer if I need them, they come quite quickly. Never known them to be long to answer at all”; “I have 20 hours (1:1) a week. I have bank staff doing 1:1, also [staff member] does the odd afternoon. The 1:1 is for getting out and keeping active”; “I use my call bell, they come when they should, I don’t use it that much.” A relative told us, “I think there is enough staff. What I have liked is that staff are very dedicated.”

Staff told us there were not enough staff on duty to support people effectively. Comments included, “I don’t think there is really enough staff on shift, we can’t take people out when they want to go out and this includes if they wanted to go to a show or theatre”; “If only 2 staff are on it is impossible to go out, they plan to improve this. [Person] is not always getting his 1:1 hours (20 per week)”; “Yes and no to enough staff, an extra staff member would enable people to get out in the community, it is hard to get people to go out in the community with 2 on shift” and “There is not enough staff to meet people’s needs. They (people) are existing not living. This applies to the night staff especially. They (management team) have implemented extra staff now and have put in a request to KCC (local authority).” Staff told us they completed training to support them to meet people’s needs safely. Staff said that since there had been a change in management they had started to receive supervision meetings with their line manager. Staff told us they felt well supported by the management team. A staff member said, “I have absolute confidence in the new management team.” A staff member told us about an issue that had happened a few weeks prior to our assessment when a new member of night staff who had not completed their induction and did not know people well was put on a night shift on their own. This caused the staff member distress and put them at risk because people required the support of 2 staff members with their moving and handling. The management team told us they were reviewing the staffing levels.

We observed the staffing rota for the day of our site visit only had 1 member of night staff allocated and we discussed this with the management team in the morning.

At the end of the day we asked if an additional staff member had been sourced to work the night. The management team advised that they hadn’t done this. We discussed with them concerns that people living at the service had an assessed need of 2 staff to support them and only allocating 1 staff member on shift was putting the staff member and people at risk. The management team then made arrangements for an agency worker to work the night shift alongside the permanent staff member. We observed 1 person utilising a 1:1 support worker to access the local community to pursue their leisure interests.

There were not always enough staff deployed on shift to meet people’s needs and provide safe care. The provider had not reassessed safe levels of staffing as people’s needs changed or engaged with commissioners to review this. This had put people and staff at risk of harm from unsafe moving and handling practice and increased fire risk. After the assessment visit, action was taken to review safe staffing levels and commissioners from the local authority were contacted to discuss safe levels of staffing. Staff had supervision meetings and induction was a mixture of training and shadowing experienced staff to gain confidence and experience. Most staff had received the training required to meet people’s assessed needs. However, training records showed only 7 staff in total had done training relating to emergency medicines prescribed to treat epileptic seizures, despite these staff working with people on shift without any trained staff around. We raised this with the management team who put a risk assessment together to show what action staff should take if a person required this medicine. Whilst this had been put in place it would cause delays to a person being given this medicine if they needed it. Staff had not always been safely recruited. We examined 3 staff files, 1 staff file contained gaps in employment, there were no records of whether this had been explored. The staff file also contained inconsistencies between employment dates in the application against the references supplied. We raised this with the managers who spoke with the HR team who carried out these checks. They provided additional information to show they had now explored the gaps. Files contained copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

People benefitted from a clean and tidy environment. A person told us, “[Staff member] is my keyworker. He does my cleaning once a week.” Relatives said, “The home is always clean and tidy” and “It is always clean and doesn’t smell at all.”

Staff told us they had sufficient equipment and PPE (Personal protective equipment) to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member said, “We have plenty of PPE.”

We observed that some waste bins around the service increased the risk of infection as they were not pedal bins, which meant staff and people needed to touch the bins to place items inside. We reported these issues to management team who told us new bins had been ordered. The provider was promoting safety through the layout and hygiene practices in the rest of the premises. There were no restrictions to visitors. We observed visitors coming and going freely during the assessment. We observed that the staff were using PPE effectively and safely.

The provider had systems and processes in place to assess and manage the risk of infection. They were able to detect and control the risk of it spreading and share any concerns with appropriate agencies promptly. The provider had a daily cleaning program in place. Support workers completed cleaning tasks and they supported people to carry out cleaning, which included deep cleans for people’s rooms. The provider had plenty of PPE in place to keep people and staff safe. The kitchen area was clean and well managed.

People received their medicines safely. People told us, “They do my medicines. If I need to have a tablet I just ask” and “If I have a headache I can ask for a Paracetamol.”

People received their medicines from trained staff. The staff informed us they received training. The management team told us staff were competency assessed to handle medicines safely. People were supported by the local GP. Medicines were safely stored. Recording of medicine administration was done on an electronic system and each individual staff member trained to administer medicines had their own log in.

The provider had systems and processes in place to manage medicines, these were not fully robust and some improvements were identified. We checked medicines stock for each person and found discrepancies for 2 people in the amount of medicines held in stock against the records of stock. We checked this with a staff member who verified the medicines did not tally. They reported this as a medicines incident so that the management team could investigate this. For medicines given ‘as required’ (PRN), such as pain relief there were protocols in place, providing details of when a person may need the medicine. Room temperatures were recorded daily to ensure medicines were stored at the correct temperatures. Cupboards were locked and controlled medicines were stored in accordance with national guidance. Medicine trolleys were locked and were securely attached to the wall. Medicine trolleys were organised with each person’s name on the front of the box containing their medicines