Archived: Burnham

Updated 15 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 unannounced inspection took place on the 19 April 2016. The inspection team consisted of one inspector.

Before the inspection, the provider completed 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 looked at all the other information we held about the service, including previous inspection reports, complaints and notifications. A notification is information about important events which the provider is required to tell us about by law. We used all this information to decide which areas to focus on during our inspection.

We met the four people currently living at the service. Some people had limited communication but understood our questions and were able to give their responses through using a thumb up and thumb down sign. We spent time observing how a person with limited communication was supported by staff and interacted with them.

We spoke with four relatives, the registered manager, and three staff who worked in the service. We contacted three social care professionals and received feedback from two.

We looked at two people’s care and health plans, risk assessments and medicine records. We also looked at operational records for the service including: staff recruitment, training and supervision records, staff rotas, accident and incident reports, servicing and maintenance records and quality assurance surveys and audits.

Updated 15 June 2016

We carried out this unannounced inspection on 19 April 2016. Burnham is a service for up to five people with physical disabilities. At the time of inspection there were four people living in the service. At a previous inspection on 6 January 2015 we found the provider was not meeting all the requirements of the legislation in respect of fire evacuation arrangements, record keeping and quality monitoring; we asked the provider to write and tell us what action they were going to take to address the specific shortfalls identified which they had done.

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There was a registered manager in post. 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 we found that staff recruitment was conducted safely but important information the service is required to keep in respect of staff recruitment and the checks made had not been retained.

People were protected from harm because there were enough staff available to support them both in the service and when out in the community. Staff were trained to meet people’s needs and they discussed their performance during one to one meetings and discussions with the registered manager.

Staff felt listened to and supported and had regular staff meetings; they were provided with regular opportunities to discuss their training and development with the registered manager. Not everyone we met was able to verbally express their views but through gestures and signs and those that could tell us people showed that they were happy living in the service and felt well supported by staff. Staff showed affection and positive engagement with the people they supported. Staff spent time with people to understand their experiences of support and if changes were needed. Relatives told us that they were kept informed about their relative’s welfare and were invited to contribute their views at placement reviews when they attended. Staff monitored people’s health and wellbeing and supported them to access routine and specialist health when this was needed.

People were given individual support to participate in their own interests and hobbies. Risk assessments were completed for each person regarding the support they needed with their environment and the activities they participated in, this helped staff to understand how to protect them from harm, these were kept updated or amended whenever changes occurred. Accidents and incidents were monitored by the provider to see where improvements could be made to prevent future occurrence. Individualised guidance was available to staff to help them understand how to work positively with people whose behaviour could be challenging to others.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider understood when an application should be made and the service was meeting the requirements of the Deprivation of Liberty Safeguards.

People were supported by staff who had been trained to recognise and act on any suspicion of abuse and understood the whistleblowing policy and their responsibilities to report concerns. Guidance was available to staff in the event of emergency events so they knew who to contact and what action to take to protect people and keep them safe. People, staff and relatives were confident they could raise any concerns with the registered manager or outside agencies if this was needed.

People lived in a well maintained environment that was decorated and furnished to a high standard, it was visibly clean and tidy and people were enabled with staff support to personalise their own personal space. Equipment checks and servicing were regularly carried out to ensure the premises and equipment used was safe. Fire detection and alarm systems were maintained; staff understood how to protect people in the event of a fire as they had undertaken fire training and took part in practice drills.

People ate a varied diet and were consulted about the development of menus which took account of their personal preferences. Medicines were managed safely by trained staff. People and their relatives were routinely asked to comment about the service and action was taken to address any areas for improvement. A new quality assurance system had been implemented to enable the provider and registered manager to assess and monitor the quality of service delivery to ensure standards were maintained.

We have made one recommendation:

We recommend that the provider monitors whether all staff are participating in a minimum of two fire drills annually in accordance with recommendations for staff contained in the Regulatory Reform (Fire Safety) Order 2005.