12 April 2022
During an inspection looking at part of 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.