Archived: Burnham

Updated 10 January 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 for the service under the Care Act 2014.

This inspection took place on 30 November 2017. The inspection was unannounced. The inspection was carried out by one inspector.

We carried out the inspection because the provider had changed their legal entity in December 2016. We inspect new services within 12 months of them being registered.

Before 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 improvements they plan to make. We also reviewed the information we held about the service including previous inspection reports. These inspection reports related to the same service but the provider’s previous legal entity. We looked at notifications which had been submitted. A notification is information about important events which the provider is required to tell us about by law.

We spent time speaking with three people who lived at Burnham. We observed care and support in communal areas.

We contacted health and social care professionals to obtain feedback about their experience of the service. These professionals included local authority commissioners. We spoke with five staff; including care staff, senior care staff, the registered manager and the visiting group manager.

We looked at three people’s personal records, care plans and medicines charts, risk assessments, staff rotas, staff schedules, three staff recruitment records, meeting minutes, policies and procedures.

We asked the registered manager to send us additional information after the inspection. We asked for copies of the training matrix and policies and procedures. These were received in a timely manner.

Updated 10 January 2018

The inspection took place on 30 November 2017. The inspection was unannounced.

At the previous inspection on 19 April 2016 when the provider and service was registered as a different legal entity. There was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. This related to records missing from staff recruitment files within the safe domain.

After the inspection the provider sent us an action plan on 16 June 2016 which detailed how they planned to address the breach of Regulations. The action plan stated they had met the Regulation by May 2016.

Burnham is a care home providing accommodation and personal care for up to five people with physical disabilities. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection five people lived at the service. Three people lived on the ground floor and two people lived on the top floor which was accessible to them because a through floor passenger lift was fitted.

The service had 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.

At this inspection people told us they enjoyed living at the service. They got on well with staff and we saw that people were comfortable and relaxed.

The provider had not always followed effective recruitment procedures to check that potential staff employed were of good character and had the skills and experience needed to carry out their roles.

The service had not been adapted to ensure all areas had wheelchair access, which meant people were unable to access to kitchen. We made a recommendation about this.

Effective systems were not in place to enable the provider to assess, monitor and improve the quality and safety of the service. Records were not always complete, accurate or securely stored.

People's care plans detailed most of their care and support needs. However, care plans did not all reflect each person's current need or specific healthcare needs.

Appropriate numbers of staff had been deployed to meet people's needs. Staff had attended training relevant to people's needs and they had received effective supervision from the registered manager.

Risk assessments were in place to mitigate the risk of harm to people and staff. Medicines had been well-managed.

People were provided with meaningful activities to promote their wellbeing. People accessed their local community both with their relatives and with the staff.

People had choices of food at each meal time. People had adequate fluids to keep themselves hydrated. A person received their fluid and food through percutaneous endoscopic gastrostomy (PEG), they received the correct amount of meals as detailed by specialists to keep them healthy.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People were not deprived of their liberty, so not applications had been made.

Staff knew and understood how to protect people from abuse and harm and keep them safe.

People were supported and helped to maintain their health and to access health services when they needed them.

Maintenance of the premises had been routinely undertaken and records about it were complete. Fire safety tests had been carried out and fire equipment safety-checked.

Staff were cheerful, kind and patient in their approach and had a good rapport with people. The atmosphere in the service was calm and relaxed. Staff treated people with dignity and respect.

People were supported to maintain their relationships with people who mattered to them. Relatives and visitors were welcomed at the service at any reasonable time.

People and their relatives had opportunities to provide feedback about the service they received.

Compliments had been received from relatives through the completion of their surveys.

People and their relatives knew who to talk to if they were unhappy about the service. No complaints had been received.

Relatives and staff told us that the service was well run. Staff were positive about the support they received from the management team. They felt they could raise concerns and they would be listened to.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.