The Burrows

Updated 13 October 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Treehaven Bungalows is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

People living in the service were unable to tell us verbally about their care, so we observed how staff supported people. We spoke with three relatives and six members of staff. This included the registered manager, deputy manager and four members of care staff.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 13 October 2021

About the service

Treehaven Bungalows is a care home providing personal care and support to people with a learning disability and /or autistic people. The service can support up to 11 people. At the time of inspection there were 10 people living in the home. Treehaven Bungalows is two conjoined bungalows with a majority of the accommodation downstairs, and each bungalow has an upstairs flat.

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

Safeguarding incidents were not always reported to the relevant authorities, and systems to monitor accidents and incidents was poor and lacked comprehensive oversight. Health and safety audits failed to address concerns found within the environment.

There was a lack of effective governance systems in place to monitor and assess the quality of service being delivered. The provider did not maintain oversight of how the service was being delivered. Relatives had not been asked to provide feedback about how they thought the service had been run for a number of years.

Risks in relation to people’s health and wellbeing had been identified and planned for and people were cared for by staff who understood their care needs well. There were safe systems in place around the administration and management of medicines, and staff had received training in relation to this.

People’s relatives and staff spoke positively about how the service was run by the registered manager. People’s relatives were complementary about how their family members were cared for and how they were supported to achieve good outcomes. Staff felt supported in their roles and felt able to put forward ideas about how to improve the service.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of the key questions of safe and well-led, the service showed how they were meeting some of the principles of Right support, right care, right culture. Based on our findings, the provider did not take adequate steps to report and investigate safeguarding concerns. Our observations and conversations with people’s relatives and staff assured us care was delivered in a person-centred way.

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 this service was good (published 25 March 2019).

Why we inspected

This was a focused inspection to check on a specific concern we had about the provider’s governance systems and oversight of the service.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Treehaven Bungalows on our website at www.cqc.org.uk.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safeguarding service users from abuse and improper treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.