Burleys Wood is registered to accommodate up to 60 people who require nursing care or support which their personal care. At the time of the inspection there were 55 people using the service. The premises was purpose built and accommodation was provided in six units over two floors. Each unit comprised of 10 en-suite bedrooms, a communal lounge, dining room and kitchenette. There was level access throughout the service and grounds and a shaft lift to the first floor.
This comprehensive inspection was unannounced and took place on the 14 October 2015.
The service did not have 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. The service was being managed on a day to day basis by an acting manager who was being supported by the area manager and senior management team.
The provider had systems in place to assess and monitor the quality of the services provided. However these had not been consistently followed. Therefor shortfalls had not always been identified and rectified. This is an area of practice that needs improvement.
People were positive about the service and were able to see their friends and families as they wanted. All the visitors we saw told us they were made welcome by management and staff. A relative told us “We’ve noticed that they don’t just look after the residents here, but they look after the families and relatives too, everything has always been to our expectations and (person’s name) has been very happy here”.
Everyone we spoke with liked the home cooked food and told us there was a choice of what and where to eat at meal times. One person told us “The food is very good”. Another person told us “I enjoy my meals, the food is excellent, we’re a bit spoilt really”. People who needed help to eat and drink were supported appropriately.
Staff knew the people they were supporting and were aware of their personal preferences, likes and dislikes. Care plans were in place detailing how people wished to be supported and people and / or their representatives were involved in making decisions about their care. Where people lacked the capacity to make specific decisions they were being supported to make decisions in their best interests. They were supported with their healthcare needs and staff liaised with their GP and other health care professionals as required.
People and their visitors described staff as being kind, patient and considerate. One person told us “I know they really love me here and they’ll give me a kiss and a cuddle if I want one”. Another person told us “They’re very friendly (the staff), you can always have a laugh and they always seem to work well together”.
It was clear that people enjoyed the group activities on offer and the visits by entertainers. The activity staff spent one to one time with people that did not want to join group activities. A reminiscence area had been initiated on the ground floor referred to as ‘the street’ specifically to help engage and stimulate people living with dementia.
There was enough staff with the right skills and experience to meet people’s needs. One person said “You ring your bell and they’re here like a rocket. Even if you accidentally knock it and it goes off, they don’t make you feel awkward”.
Systems for recruiting new staff included security and identity checks and at least one reference from a previous employer. Staff were aware of their responsibility to protect people from harm or abuse. They knew the action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to the acting manager or senior member of staff.
Staff received regular training and were knowledgeable about their roles and responsibilities. They had the skills, knowledge and experience required to support people with their care and support needs. They felt supported within their roles, describing an ‘open door’ management approach, where the acting manager and management team were available to discuss suggestions and address problems or concerns.
People were positive about the management of the service. One person told us “Our friends that come couldn’t believe how good it was here and we spoke to (acting manager) to tell her so”. People and relatives alike all said that they had no hesitation in raising concerns or complaints with the management and that they felt they were approachable and would be listened to. One person told us “You only have to mention something and if they can they’ll act upon it”.
Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future. Risks associated with the environment and equipment had been identified and managed and emergency procedures were in place in the event of fire.