Burdyke Lodge

Updated 18 June 2022

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 Health and Social Care Act 2008.

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 undertaken by two inspectors.

Service and service type

Burdyke Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Burdyke Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

The service had a manager registered with the Care Quality Commission. They are also the provider of the service. They are legally responsible for how the service is run and for the quality and safety of the care provided. The provider did not work at the home every day. There was a care manager and deputy manager who were responsible for the day to day running of the home.

Notice of inspection

The first day of the inspection was unannounced.

What we did before the inspection

Before the inspection we reviewed the information, we held about the service and the service provider. We sought feedback from the local authority. We looked at the notifications we had received for this service. Notifications are information about important events the service is required to send us by law. We used all of this information to plan our inspection.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

During the inspection

During the inspection we reviewed the records of the home. These included two staff recruitment files, medicine, accidents and incidents, quality audits and policies and procedures along with information about the upkeep of the premises. We looked at three care plans and risk assessments along with other relevant documentation to support our findings. This included 'pathway tracking' two people living at the home. This is when we check that the care detailed in individual plans matches the experience of the person receiving care. It is an important part of our inspection, as it allows us to capture information about a sample of people receiving care.

At the inspection we spoke with seven people, two visitors, and seven staff members. This included the provider. We spent time observing people in areas throughout the home and could see the interaction between people and staff. We watched how people were being cared for by staff in communal areas. This included the lunchtime meals.

We also received feedback through phone calls and emails from a further two relatives and three health and social care professionals who were involved with the home.

Updated 18 June 2022

About the service

Burdyke Lodge is a residential care home providing personal care to 15 people aged 65 and over at the time of the inspection. The service can support up to 27 people. People were living with a range of needs associated with the frailties of old age.

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

At the last inspection we identified improvements were needed to ensure there was an effective quality assurance system to identify concerns and drive necessary improvement. At this inspection we found some improvements had been made but these had not always been sustained. We also found that where the need for improvements had been identified action was not always taken in a timely way.

There were not enough staff employed at the home. Staff worked hard to ensure people’s care and support needs were met. However, the staffing levels impacted on other aspects of the service including the cleanliness of the home, activities for people and some aspects of quality assurance.

Environmental risks were not always managed safely. This included some aspects of fire safety and general safety and upkeep of the home. Risks to people were well managed. Staff knew people well and understood how to support them safely. There was a large, well-kept garden where people enjoyed spending time during the warmer weather.

People received care and support that met their individual needs and wishes. Staff understood the care and support people wished to receive. This included their individual choices and preferences. There was a positive culture at the home and staff were committed to ensuring people lived happy lives.

People were protected from the risks of harm, abuse or discrimination because staff knew what actions to take if they identified concerns.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported 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 and update The last rating for this service was requires improvement (published 16 October 2019). There was one breach of regulation.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended that the provider ensured staff received appropriate practical training. We also recommended they work with people to improve and develop meaningful activities for everybody. At this inspection we found the provider had not ensured staff received appropriate practical training. We found there had been some improvements to meaningful activities. However, due to current staffing concerns these improvements had not been maintained.

The last rating for this service was requires improvement (published 16 October 2019). The service remains rated requires improvement.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 12 August 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve their quality assurance systems.

This inspection was also, prompted in part, due to concerns received about fire safety risks. A decision was made for us to inspect and examine those risks.

We undertook this focused inspection to check they had followed their action plan, to check if they now met legal requirements and to examine the risks identified to us. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

We have found evidence that the provider needs to make improvements. Please see the Safe, Responsive and Well-led sections of this report.

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

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains Requires Improvement.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Burdyke Lodge 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 monitor the service and will take further action if needed.

We have identified breaches in relation to the staffing, risk management and the quality assurance systems at this inspection.

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

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.