• Care Home
  • Care home

Burlington Villa

Overall: Requires improvement read more about inspection ratings

15 Burlington Villa, Sherwood, Nottingham, Nottinghamshire, NG5 2GR (0115) 960 2738

Provided and run by:
MGB Care Services Limited

All Inspections

During an assessment under our new approach

Burlington Villa is a ‘care home’ providing personal care and support to older people and people living with dementia. At the time of the inspection, the service was supporting 8 people with their personal care needs. Burlington Villa was last rated Requires Improvement (published 18 October 2022). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 15 April 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at 10 quality statements; 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; Governance, management and sustainability; and Freedom to speak up. We assessed some but not all quality statements at this visit which means we use the ratings from the previous inspection to rate the key questions of effective, caring and responsive. This assessment did not cover all parts of our Single Assessment Framework, therefore we have only updated scores and ratings for those areas which we have assessed. We will carry out future assessments to cover other parts of the Framework and will update our website with our findings.

20 June 2022

During a routine inspection

About the service

Burlington Villa accommodates nine people in one adapted building. The service provides support to people with a learning disability. At the time of our inspection there were nine people using the service.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

The service was not always able to demonstrate how they were meeting some of the underpinning principles of right support, right care, right culture.

Right Support

Staff did not always support people to have the maximum possible choice and control over their own lives.

The service had locked all internal and external doors to manage the behaviour of one person but consequently it impacted on other people’s freedom. There was a wider concern relating to how the provider manages behaviours that challenge and whether the service supported a human rights approach.

Staff did not always support people with their medicines in a way that achieved the best possible outcome. The service did not maintain accurate and up-to-date records about people’s medicines.

When ‘as required’ (PRN) medicines were used to manage behaviour, records were not thorough or detailed. There was no evidence of post incident analysis or evidence of how well the medicines were effective in managing the behaviour.

People were supported by staff to pursue their interests and make plans for the future.

The service gave people care and support in a safe, clean and well-maintained environment. People had a choice about their living environment and were able to personalise their rooms.

Right Care

Some people were able to express their views and make choices.

People received kind and compassionate support. Staff were appropriately trained and had completed training in autism and equality and diversity.

People had access to healthcare professionals and were supported by staff to attend appointments.

Care plans were person-centred and demonstrated a good amount of knowledge about the people they supported.

Right Culture

Restrictions were put in place with no evidence of the least restrictive options being considered. There was limited opportunity for staff to learn from incidents and improve practice.

Audits were completed at the home to monitor the service and make any improvements needed although they did not always identify shortfalls we found at this inspection.

Staff turnover was very low, this gave people a more consistent approach from staff who knew them well. Some staff members had been in post for several years.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for the service under the previous provider was good, published on 1st November 2017.

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to the safe care and treatment, safeguarding service users from abuse and improper treatment and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

14 September 2017

During a routine inspection

We carried out an unannounced inspection of the service on 14 September 2017. Burlington Villa is a care home which provides residential care for up to nine people who have a learning disability. On the day of our inspection nine people were using the service and there was a registered manager in place.

At the last inspection, in August 2015, the service was rated Good. At this inspection we found that the service remained Good, however the rating for the Caring question had improved from Good to Outstanding. .

People continued to feel safe and staff ensured that risks to their health and safety were reduced. There were sufficient staff to meet people’s needs in a timely manner and systems were in place to support people to take their medicines.

Staff received relevant training and felt well supported. People were asked for their consent and appropriate steps were taken to support people who lacked capacity to make particular decisions. People were supported to eat and drink enough to maintain good health.

The service was exceptionally caring. Positive relationships existed between people who used the service, their relatives and staff. Staff were extremely kind and caring and treated people with dignity and respect. People's diverse needs were recognised and catered for and their rights to privacy and dignity were valued and respected.

People's right to make choices was respected by staff and they had access to advocacy to help them express their views if needed. Staff had an in depth understanding of how people communicated and had insight into the anxieties experienced by people who used the service and used this to shape people’s support and routines. The culture of the service was focused on enabling each person to live a fulfilled life, as independently as possible and this resulted in people being valued and treated as individuals.

People received person-centred and responsive care from staff who had a clear understanding of their current support needs. Care plans were in place which provided detailed information about the care people required. People knew how to make a complaint and there was a complaints procedure in place.

There was an open and transparent culture which enabled people and staff to speak up if they wished to. The management team provided strong leadership and a clear direction to staff. There were robust quality monitoring procedures in place.

Further information is in the detailed findings below.

28 August 2015

During a routine inspection

We performed the inspection on 25 August 2015. Burlington Villa is run and managed by MGB Care Services Limited. Burlington Villa is a care home which provides residential care for up to nine people who have a learning disability. Nursing care is not provided at the service. On the day of our inspection eight were using the service. The service is provided across three floors with a passenger lift connecting the floors.

The service had a registered manager in post at the time of our unannounced inspection. 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 and associated Regulations about how the service is run.

People were protected from the risk of abuse as staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The registered manager shared information with the local authority when needed.

People received their medicines as prescribed and staff had received training to ensure the management of medicines was safe.

People were supported by a sufficient number of staff and the provider had ensured appropriate checks were carried out on staff before they started work.

People were encouraged to make independent decisions. Staff were aware of legislation to protect people who lacked capacity and decisions were made in their best interests. We also found staff were aware of the principles within the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.

People were supported to maintain a nutritionally balanced dietary and fluid intake and their health was effectively monitored.

Positive and caring relationships had been developed between people and staff, and staff responded to people in a compassionate manner. People were supported to make day to day decisions and were treated with dignity and respect by staff.

People who used the service, or their representatives, were encouraged to be involved in decisions about the service and systems were in place to monitor the service provision. People said they felt they could report any concerns to the management team and felt they would be taken seriously.

26 April 2013

During a routine inspection

We spoke with two of the nine people living at the service and observed others during the inspection. We also spoke with two staff and the acting manager to help us assess compliance.

There were significant improvements in the care plans in place and these were helpful and up to date. One person told us, "I think what is written is right about me. I get the care and support I need when I need it, I don't need much, only to go into the community.' People had their health and recreational needs met well.

People lived in a comfortable environment and the premises were safe for them to live in.

People we spoke with said they were happy at the service. They knew they could complain. One person commented, 'I have not had to complain but I would speak to (the acting manager), she is really good and I know that she would sort it out.' The staff knew how they should respond to complaints. This meant there were effective systems in place for responding to concerns.

28 December 2012

During a routine inspection

We spoke with one of the nine people living at the service, observed and spoke with someone with more complex communication needs and we spoke with two of the staff working at the service to help us form a view about how care was being delivered to people and the impact this had on them.

Improvements had been made to the systems to make sure people could make their own decisions unless they did not have the capacity to do this for themselves. This meant their rights were considered.

There was mixed evidence about how people's care and welfare needs were met. In most cases this was done well, with warmth, compassion and understanding. However we found the staff did not have the appropriate guidance to help them understand more challenging needs and to help them respond consistently to meet these needs. We thought improvements were needed.

We found there were improvements in the arrangements for making sure people took their medication as their doctor had prescribed. This meant people got their medicines at the right time.

We looked at the staff files of people who had just started working at the home and we saw they had been recruited safely to make sure they were suitable to work with people living at the home.

We found the complaints system was not good enough and did not follow the policies the providers had in place to make sure they could investigate and respond to people with concerns.

21 November 2011

During an inspection in response to concerns

We visited this service because we were concerned that we had not visited for some time. We wanted to make sure that people were getting good care and that the service were compliant.

The people we spoke with told us they were very happy living at the service. They told us they liked the staff. We observed the staff working with people during our visit and saw that they were calm and gave people support and reassurance. We also saw evidence to show that they were following people's written care plans.

People told us they helped with daily chores such as cleaning, vacuuming and drying the pots. They liked this because it helped them stay independent. They both told us they liked going out and they said they went out a lot.

The people we spoke with told us they liked the staff and one person told us the staff seemed to know their job well. "I get on well with the staff, they are kind and listen to me." From what we saw, the staff seemed confident, competent and they understood the needs and wishes of the people they looked after.