Burleys Wood

Updated 13 July 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating under the Care Act 2014.

The inspection took place on 19 and 20 March 2018 and was unannounced. On the first day of inspection the inspection team consisted of one inspector, a nurse and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. In this case the expert-by-experience had experience of older peoples’ services. On the second day of inspection the inspection team consisted of an inspector and an inspection manager.

Before the inspection we looked at information we held, as well as feedback we had received about the service. We also looked at notifications that the provider had submitted. A notification is information about important events which the provider is required to tell us about by law. Prior to the inspection we asked the provider to complete a Provider Information Return (PIR), this is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. We used all of this information to decide which areas to focus on during our inspection.

During our inspection we spoke with 11 people, seven relatives, four visitors, a visiting healthcare professional, five members of staff and three members of the management team, one of whom was the registered manager. Prior to the inspection we contacted a healthcare professional from the local authority. Following the inspection we contacted a tissue viability nurse (TVN) for their feedback. We reviewed a range of records about people’s care and how the service was managed. These included the individual care records for seven people; seven electronic medicine administration records (EMAR), six staff records, quality assurance audits, incident reports and records relating to the management of the home. We 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 observed care and support in the communal lounges. We also spent time observing the lunchtime experience people had, the administration of medicines and various activities that were taking place throughout the inspection.

The service was last inspected on 14 October 2015 and received a rating of ‘Good’. At this inspection the home remains ‘Good’.

Updated 13 July 2018

The inspection took place on 19 and 20 March 2018. The first day of inspection was unannounced. On the second day of inspection the registered manager, deputy manager, area manager, staff and people knew to expect us. Burleys Wood is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Burleys Wood is situated in Crawley in West Sussex and is one of a group of services owned by a national provider, Shaw Healthcare Limited. Burleys Wood accommodates 60 people across six separate units, each of which have separate bedrooms with en-suite shower facilities, a communal dining room and lounge. There were also gardens for people to access and a hairdressing room. The service provided accommodation for older people, those living with dementia and people who required support with their nursing needs. At the time of the inspection there were 54 people living at the service.

At the previous inspection on 14 October 2015 the service was rated as ‘Good’. Areas in need of improvement were identified. These related to there being no registered manager and a lack of quality assurance audits to ensure that the service continually improved. At this inspection improvements had been made and the service remained 'Good'.

The management team and staff did not always have a good understanding of the Deprivation of Liberty Safeguards (DoLS) and had not always worked in accordance with this. Staff gained people’s consent before supporting them with day-to-day tasks but there was an inconsistent approach to formally gaining consent on people’s behalves when they lacked capacity. This is an area of practice identified as being in need of improvement.

The service was fun, lively, stimulating and inclusive. Staff ensured that all people were provided with access to events and meaningful activities to meet people’s interests. There were adaptations to the type of activities to ensure they were accessible for all. These included garden parties, summer fairs, sports days and pantomimes. People were involved in choosing the events and activities. They were encouraged to become involved in facilitating these. They helped out on stalls at the summer fair and took part in races during the sports day. These events and activities provided people with opportunities for improved socialisation. The registered manager and staff ensured that people led fulfilled lives. People had learnt new skills and were encouraged to participate in activities that they were interested in. One person had got married and people and staff had been involved in the preparations and the wedding itself.

There was a registered manager in place. A registered manager is a ‘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. Comments from people, their relatives and visitors, staff and healthcare professionals were positive about the leadership and management. They recognised that the registered managed ensured that the service people received continually improved. The provider and management team were proactive and involved in projects to monitor people’s health, provide access to integrated healthcare and to develop the service and practices of staff.

The provider had a clear set of values that all staff embraced. These encompassed a person-centred approach and these values were embedded in the culture and the practices of staff. The provider and management team had good quality assurance processes and audits that monitored the practices of staff and the effectiveness of the systems and processes at the home. Action plans were implemented as a result of audits to ensure that any improvements noted were planned for and completed. The provider, management team and staff, worked with external agencies and professionals and continually reflected on their practice and learned from incidents and occurrences to ensure that the service continually improved.

People were positive about living at the service. They told us that they were well-cared for and content. People, relatives and healthcare professionals told us that staff were consistently kind, caring and compassionate and our observations confirmed this. Comments from people included, “They care very well for us, even though they have a very long day” and “Staff are very good, kind and they are lovely”. A relative told us, “All the carers are lovely, friendly and warm. The carers have time for the residents”. People were treated with respect and dignity, their privacy maintained. Independence was promoted and encouraged and people could choose how they spent their time.

People received timely interventions when they were unwell and had access to medicines to maintain their health. People were supported by external healthcare professionals and there were good links and communication to ensure that people received a coordinated approach to care. People received good end of life care. A healthcare professional told us, “I feel that at this home, when we know a person’s health is deteriorating and their death is imminent, that they focus on what the person wants. I see a lot of good deaths here that show they provide a good level of care”.

Staff had access to learning and development and support from external healthcare professionals to develop their skills and understanding. People were safe and there were sufficient staff. Risks were assessed and managed and people were supported by staff that understood what to do if there were concerns about a person’s safety. People were protected from infection and told us that the service was clean and our observations confirmed this.

The service was designed in such a way to enable people to orientate themselves around the building and enjoy time on their own as well as interact with others. People had access to meaningful interactions with staff. People were involved in the development of care plans and were able to voice their wishes and contribute to a plan of care that was specific to their goals and aspirations. People were involved in decisions that affected their lives at the service. Regular meetings ensured that people were able to express their wishes and preferences. The registered manager welcomed feedback and used this to continually improve the experiences of people. People told us that they enjoyed the food and were provided with choice. People’s hydration and nutritional needs were met.

A comment made by one person, summed up people’s feedback about their experience living at the service. They told us, “The best thing is peace of mind and I have nothing to worry about in here”.