Burnham 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

We assessed 4 quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating for the last inspection, our rating for the key question remains requires improvement. We have identified 4 breaches of the legal regulations. People were not routinely protected from abuse, the service failed to always recognise or act on allegations of abuse. The risks to people because of their medical conditions were not always assessed in a timely manner to prevent harm. Where risk assessments were completed these did not always mitigate the potential harm to people. Medicines were not always managed safely. The ordering process for prescribed medicines was not safe and effective. As a result, people went without essential prescribed medicines. Over-the-counter medicines held in stock were out of date. People were not routinely supported by staff who had been recruited safely which had the potential for an increased risk to people. Staff working in specific roles did not routinely have effective training to ensure they had the skills and knowledge to support people safely.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at Burnham Lodge. Comments included, “They push me everywhere so I'm safe. I have a pendant to press, they don't always answer straight away but they do answer. I don't expect it straight away as they have a lot of patients'', “If I didn't feel safe, I think I could find another care home” and “Oh my god yeah. I feel satisfied with everything they are very good to me”. This was also supported by what relatives told us. Comments from relatives included, “Burnham Lodge is a good example of how well a home is run, by sensitive people” and “From what I see mum looks well looked after, I’ve been happy with the care since she has been there”.

Senior staff told us they were aware of safeguarding concerns which had been identified by third parties. However, nursing and care staff told us they did not always have confidence in the management team to follow up on safeguarding concerns. This was supported by what we found.

We observed staff were respectful towards people. We found no evidence of unnecessary restrictions on people. Where restrictions were in place, for instance, bed rails, records showed the need for them had been fully assessed.

The service failed to have systems and processes in place to ensure people were protected from abuse. Staff failed to identify events which had the potential to cause harm to people and report them to the local safeguarding authority. For example, we found people had told staff they had been assaulted and this had not been investigated as a safeguarding concern. We found where people had missed essential prescribed medicines, which had the potential to increase the risk of harm, these were not reported to the local authority for investigation.

People and their relatives told us they felt risks to their health, safety and welfare were managed well within the home. Comments from people included, “They are very trustworthy, they work hard. The accommodation is very good. I have nothing to criticise'' and “Yes, they discuss things [risks] with me.” Another person told us “I have slipped off my chair once onto the floor, they got a hoist and put me into bed. They put a plastic cushion and put it on the chair so I can't slip off.” This was supported by what relatives told us. Comments included, “The first few days the chef spoke to me, as he was concerned, she [family member] wasn’t eating a lot. I thought that was very good.”

Staff who provided feedback to us they were aware of risks posed to people. They were able to advise us they had access to care plans and risk assessments. Some staff told us they were updated with any changes to the level of risk to people in daily handover meetings. Other staff told us they were concerned about risk management within the home. For instance, they felt there had been delays in the provision of fall sensor and pressure relieving equipment which we saw impacted people.

We observed equipment was in place to support staff to manage risk of harm to people. This included bed rails and pressure relieving mattresses as examples. We observed staff were respectful when supporting people move positions, ensuring good communication throughout the manoeuvre.

The processes and systems in place to manage potential risk of harm to people were not effective. We found staff did not routinely follow the provider’s policy on risk management. Risk assessments were not routinely completed in a timely manner. When risk assessments were completed, they did not always contain enough information for staff to mitigate harm. The risk assessment policy indicated a risk matrix and register should be in place. The registered manager confirmed these were not in use.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives were happy with the quality and number of staff. They commented, “They [the home] seem well staffed at the moment, things have improved on that front. There is always someone in and out of the room. I was there yesterday and 3 times somebody came in, in the one and a half hours I was there,” and “Staff are very well trained, attentive and caring people. They [staff] are very good, they [staff] do train, they have training days. They [staff] do that bit extra, they [staff] think of extra things. They [staff] are considerate. Staff are happy, playful and it’s a really nice happy atmosphere.”

Although the provider informed us they used a dependency tool to determine staff required, and at the time of our inspection they were providing more staff hours than assessed the feedback from staff showed staff felt the staffing levels were not sufficient as were based on the number of people living in the service as opposed to their needs. Staff told us the rota was poorly managed and this resulted in some staff having to work long stretches of 12-hour shifts in a row. Staff told us the registered manager provided very good dementia training. One member of staff told us “They make it very interesting.”

On the day we visited Burnham Lodge, we observed there were enough staff to support people. However, on our arrival staff we spoke with were unclear which management staff were present in the building. We observed a mealtime in the dining room. We found some staff were not as engaged as they could have been with the people they were supporting.Other staff were supportive towards people and provided dignified care and support. People appeared to enjoy communal activities which occurred throughout the day. We saw people smiling and laughing with staff.

Safe recruitment practices were not promoted, and the service was not working in line with the providers reference policy. In staff files viewed we saw 1 staff member was working at the service for over 2 years without a reference. Whilst these were obtained while this assessment was underway this was not in line with the providers policy which stated individuals will not be allowed to commence work before Burnham lodge has received responses to its request for references. In 3 of the 10 staff files viewed references were not from the staff members previous employer, and 2 of those staff had only 1 reference on file. A third staff file viewed also only had 1 reference on file. 2 of the files with 1 reference had a risk assessment completed at the point of them starting work at the service. However, this was not updated to reflect only 1 reference had been obtained after the initial induction/ shadowing period. Staff had access to e-learning and face to face training. In training records viewed we saw there was gaps in training such as emergency first aid and fire warden training. This meant there was not always a suitably trained staff member on shift to deal with emergency situations. The training records for nurses showed training was not provided for the nursing tasks they were undertaking such as catheter care, wound management, Percutaneous Endoscopic Gastrostomy (PEG) feeding, where a feeding tube is used to give food, fluid, and medicine directly into the stomach. The staff’s competencies in these tasks were not assessed to ensure that staff were suitably trained and skilled for their roles. The rotas showed the required staffing was provided most of the time with three occasions over a 6-week period where the staffing levels fell below this. We saw some staff worked up to 7 (12 hour) shifts in a row. This was feedback to the provider to address.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not always administered their medicines as prescribed. There were several examples where medicines were not administered because they were not in stock. Some people were prescribed medicines to be administered on when required basis. However, guidance in the form of PRN protocols were not always in place to help staff give these medicines consistently. Also, care plans did not always have the necessary information to guide staff to support people with their health needs. For example, one person we reviewed who was prescribed an anticoagulant, there was no information in the care plan on how to manage and monitor their side effects.

Staff were trained in medicines administration and had competency assessments completed. Staff told us they supported people and clinical healthcare professionals so that their medicines were reviewed periodically. However, staff also told us they had raised concerns with management that the processes in place at the home for medicines management were not effective, which resulted in people missing doses of their prescribed medicines. The provider informed us about the efforts made to ensure people received their prescribed medicines, for instance, after our site visit the registered manager met with the GP practice and pharmacy.

Medicines policies were in place. However, the staff did not always follow the provider’s policy and national guidance for ordering and the safe disposal of medicines. The staff did not maintain records of waste medicines. We found out-of-date over-the-counter medicines held in stock. The process of ordering medicines was not safe and effective. We found evidence people were not administered their prescribed medicines as these were not in stock. Although the provider was able to share communication with the GP and pharmacy regarding stock of medicine, we found the service could have had more immediate contact with the GP and pharmacy to rectify concerns with stock of medicines. Regular medicines audits were carried out to identify gaps and make improvements. However, the audits did not identify the concerns we found during the assessment. The process in place to report and investigate incidents was not effective.