Burnham Lodge

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 1 quality statement in the well-led key question and found areas of concern. The score for the quality statement have been combined with scores based on the rating for the last inspection, our rating for the key question remains requires improvement. We identified 2 breaches of the legal regulations. The registered manager failed to have oversight of staff and responsibilities delegated to them. This impacted on people’s safety. The provider’s systems for auditing the success of the service were not effective and did not identify the concerns we found. We found improvements were required to record management, risk management, medicine management, protecting people from abuse, training and recruitment. Alongside the service failed to make the required notifications to us and this was not identified through their own monitoring of the service. People told us they liked living at the care home and were complementary of the staff and management. They found the management team to be approachable, responsive, and friendly which they said created a positive vibe in the service. Comments included, “Oh I love it here, the carers are wonderful, the management is wonderful, they sort things out for you,” and “Whenever I have wanted to talk to somebody, management put down what they are doing and listen and do something about it. If I have a query they respond.”

This service scored 46 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff described the registered manager as ‘lovely, popular and friendly.” Some staff felt the registered manager lacked management skills to deal with conflict and issues as they arose. They told us issues raised with the management team were not always acknowledged, addressed, or investigated, which we found to be case. The failure to act on feedback placed people at risk. We found the registered manager and provider were responsive to our feedback from this assessment and took immediate actions to start to improve the service.

Systems were in place to audit the service. However, the auditing was not effective and had not identified the concerns we found in relation to risk assessments, medicine management, failures to safeguard people and make the required notifications, recruitment practices and gaps in training. People’s records were not always accurate and contemporaneous. For example, wound care plans were routinely incomplete, missing photographs and measurements under wound description. Incident reports were not routinely completed, or investigations carried out in relation to concerns raised to prevent reoccurrence. Other records relating to the running of the service, such as training records were not up to date. The service is required to make notifications to us. We found these were not completed in relation to delays in people getting their prescribed medicines, unexplained bruising and delays in getting the required equipment for people. Concerns raised by staff or family members which alleged poor practice were not routinely investigated and reported either.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.