Burntwood Lodge

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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment; the ways people’s medicines were managed and the lack of effective training and supervision.

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Leaders did not routinely reviewed incidents to identify trends, patterns or opportunities for learning and improvement. Whilst incidents were recorded, there was a lack of documented analysis to demonstrate how information from incidents was used to improve care delivery, reduce the likelihood of recurrence or inform staff practice. This meant the provider could not evidence a culture of continuous learning from safety events. The registered manager told us, “That's something probably we may need to do it more robustly.”

For people who experienced emotional distress , records had been completed following incidents. However, these records had not been analysed to identify triggers, patterns or effective preventative strategies. Without analysing this information, the provider could not demonstrate that they were using behavioural data proactively to understand people's needs, reduce risks or support positive outcomes.

However, staff responded to incidents when they occurred, and records demonstrated that immediate actions were taken to support people and reduce the risk of further harm. This included providing appropriate care, seeking additional support where required and updating relevant records following incidents. One member of staff told us, “If anyone is hurt then you have an incident chart. We look to see if it needs to go to safeguarding.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider had admitted a person to the service without a comprehensive assessment to demonstrate how their needs would be met. The provider's ‘Statement of Purpose’ did not identify the needs of the person as a client group the service specialised in supporting. A ‘Statement of Purpose’ is a document that explains the services the home provides, who it supports, how care is delivered, and the aims, values, and objectives of the service. The pre-admission assessment was limited in scope and did not sufficiently explore the person's health relates needs, potential risks, compatibility with existing residents, or whether staff had the necessary skills, knowledge and experience to meet those needs safely. As a result, the provider could not demonstrate that effective systems were in place to ensure safe admissions, continuity of care and safe transitions into the service. This placed people at risk of receiving care from a service that may not have been appropriately designed, staffed or resourced to meet their assessed needs.

However, people were supported to access hospital treatment when required and staff sought medical assistance appropriately. People had ‘hospital passports’ in place, which contained important information about their needs, preferences and communication requirements to help ensure continuity and safe care when attending hospital appointments or receiving treatment. One health professional told us of a transition from hospital, “Burntwood Lodge ensured he had all the required equipment, such a profile bed, air mattress, correct slings. They made a referral to district nursing to monitor medication. All this was done prior to the person coming home and ensured a safe and efficient transition.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Where safeguarding concerns had occurred, records did not demonstrate these had been subject to a documented investigation. Whilst incidents and concerns had been recorded, there was limited evidence to show the provider had undertaken a robust review of the circumstances, identified contributory factors, considered lessons learned or implemented actions to reduce the risk of recurrence. For example, there had been an incident where one person hit another person causing injury. There was no record of an investigation and whilst this had been referred to the local authority, there was no evidence of any outcome. The provider could not demonstrate that safeguarding concerns were always fully explored and that appropriate learning had been embedded into practice.

However, relatives felt their loved ones were safe and well cared for. Comments included, “Whenever we go, she’s always happy. [Person] loves them. She’s never unhappy. We are quite happy” and “He’s very safe. I’ve never known anything happened to him.”

People appeared comfortable and relaxed in the presence of staff and interactions were observed to be kind, caring and respectful. Staff spoke positively about the people they supported and demonstrated an understanding of their responsibilities to keep people safe from abuse and avoidable harm. Staff were able to describe the different types of abuse, recognised indicators of potential harm and knew how to report concerns in line with safeguarding procedures. One member of staff told us if they had a safeguarding concern, “I will tell my manager first and it he doesn’t take any action, they I will go to service manager.” Another said, “I would raise it. I would report it to the manager. I would also whistle blow or raise a safeguarding concern, and an investigation would take place if needed.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The provider understood their responsibilities under the MCA in ensuring DoLS applications were submitted as required.

The provider did not always work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Where people were at risk of dehydration or required their fluid intake to be tracked, there was limited oversight to ensure records were accurate, complete and reviewed. The registered manager told us, aside from 1 person whose fluids intake were recorded, they relied upon observations for the other people. This was despite 2 people having recurrent urine infections. This meant the provider could not always be assured that people were receiving sufficient fluids to maintain their health and wellbeing.

We also identified concerns regarding the monitoring and management of continence needs and constipation. Records did not consistently demonstrate that staff had sufficient oversight of people's continence care, including patterns and changes that may indicate deterioration in health or the need for further medical review. This reduced assurance that people's needs were being effectively monitored and responded to in a timely manner.

For people with stoma care needs, there was no robust oversight of stoma output. Staff were unable to demonstrate that outputs were routinely monitored and analysed where this was required to identify potential health concerns, such as dehydration, infection or changes in bowel function. The absence of clear monitoring and oversight increased the risk that significant changes in a person's condition may not be identified promptly.

Despite these concerns, risk assessments were in place for a range of other identified risks including the risk of falls, mobility and skin integrity. Staff were generally knowledgeable about people's support needs. During the assessment, we observed staff supporting a person with a moving and handling belt in a safe, respectful and person-centred manner. Staff communicated clearly with the person throughout the transfer, explaining what they were doing and offering reassurance.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider was undertaking significant building and refurbishment work at the time of the assessment. As a result, parts of the home were in a state of disrepair and did not consistently provide a well-maintained environment for people. We observed areas affected by ongoing construction works, which impacted the overall presentation of the service and reduced assurance that all areas were maintained to the standard expected for people living in the home.

Whilst refurbishment and improvement works were ongoing, the provider had taken steps to manage other risks associated with the environment. Areas undergoing work were monitored, and there was no evidence that people were exposed to immediate unsafe conditions as a result of the construction activity.

Safety checks relating to other areas of the premises and equipment were completed. Fire safety arrangements were appropriate. Required fire safety checks had been completed, equipment had been serviced, and personal emergency evacuation plans were in place where required. Staff understood the actions they should take in the event of a fire and there was evidence that fire safety systems were subject to regular review and testing.

We observed staff supporting a person who smoked. The person was provided with a smoking jacket before accessing their cigarette, in line with their assessed needs and risk management plans.

The provider did not always make sure there were 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.

Leaders and staff demonstrated a limited understanding of the principles of Right Support, Right Care, Right Culture, (RS, RC, RC) despite these being key expectations for services supporting people with a learning disability and/or autistic people. Staff had not received training in this or positive behaviour support training. The registered manager told us, “I am looking for that training, positive behaviour support. We definitely will need that training.” As a result, the provider could not be assured that staff understood how to apply these principles in practice to promote people's rights, independence, choice, inclusion and quality of life.

We also identified that leaders had not received specific training relating to supporting people with a learning disability and autistic people. Given the specialism of the service, this reduced assurance that leaders had developed and maintained the specialist knowledge required to effectively oversee the service and ensure care was delivered in line with current best practice and national guidance.

Whilst staff understood people's day-to-day support needs and positive interactions were observed, the absence of training in RS, RC, RC and the lack of specialist learning disability and autism training for senior leaders represented a gap in the provider's workforce development arrangements. Leaders and staff had also not received any training around acquired brain injury despite supporting people with this. This meant the provider could not fully demonstrate that all staff, including those in leadership positions, had been equipped with the knowledge and skills required to deliver care in accordance with recognised models of good practice.

There were sufficient numbers of staff deployed to meet people's assessed needs. People received support when required and there was no evidence that staffing levels had a negative impact on people's safety, care or wellbeing. Staff were visible throughout the inspection and were able to respond to people's needs in a timely manner. One member of staff told us, “There are enough staff to do the job. Agency staff are barely used, and everybody gets their contracted hours.”

The provider operated safe recruitment processes to help ensure suitable staff were employed to work with people using the service. Recruitment records demonstrated that appropriate pre-employment checks had been completed before staff commenced work.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified concerns regarding some aspects of cleanliness and hygiene management. During the inspection, we found a urine bottle which contained urine and had a strong odour. This indicated it had not been emptied and cleaned in a timely manner. We also observed a used continence pad that had been disposed of without being appropriately bagged before being placed in a bin. These findings increased the risk of unpleasant odours, cross-contamination and the spread of infection within the service.

Whilst these concerns were not widespread throughout the home, they highlighted the need for greater oversight to ensure expected standards of cleanliness and hygiene are maintained consistently in all areas of the service.

However, other parts of the home were clean, tidy and free from malodours. Several communal areas and people's bedrooms appeared well maintained, and staff had access to cleaning equipment and supplies to support good infection prevention and control practices. One relative told us, “She’s always very clean. She showers every morning. No concerns regarding her hygiene. [The home is] very clean, spotless.”

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.

We identified concerns regarding the safe management and governance of medicines. Thickening powder used to support people with swallowing difficulties was stored in an unlocked kitchen cupboard. This did not promote secure storage and increased the risk of unauthorised access or inappropriate use. We also found the keys to the medicines cabinet had been left unattended on top of the cabinet. This meant medicines could potentially be accessed by individuals who were not authorised to handle them and did not reflect good medicines security practices. This had also been identified by a visiting external consultant in May 2026 where they stated this had been a recurring concern.

Handwritten medicine administration record (MAR) entries were not always supported by two staff signatures to verify their accuracy. This reduced assurance that changes and transcriptions of medicines information had been appropriately checked, increasing the risk of recording errors. In addition, 'when required' (PRN) protocols were not always person-centred or specific to the individual. Guidance lacked sufficient detail to guide staff on the circumstances in which medicines should be administered, the expected outcomes, and any alternative strategies that should be considered before administration. This created a risk of inconsistent practice and reduced assurance that PRN medicines would always be administered in line with people's individual needs and preferences.

We also found that care plans contained lists of people's prescribed medicines; however, these did not state what each medicine had been prescribed for. This meant staff did not always have clear guidance regarding the purpose of individual medicines and how they contributed to managing people's health conditions.

However, people received their medicines as prescribed. MAR charts demonstrated that medicines had been administered, and there was no evidence that people had routinely missed prescribed medicines. Staff responsible for administering medicines were able to describe people's medicine support needs and medicines were available when required.