Background to this inspection
Updated
23 August 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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 comprehensive inspection took place on 18, 20 and 29 June 2018 and was unannounced.
On the first day of this inspection the inspection team consisted of one adult social care inspector and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert-by-experience who assisted with this inspection had knowledge and experience relating to people who had mental health needs. The second and third day of inspection was undertaken by one adult social care inspector.
We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed the information we held about the service, such as notifications we had received from the registered manager. A notification is information about important events which the service is required to send us by law.
We sought feedback from the commissioners of the service prior to our visit. Commissioners are people who work to find appropriate care and support services for people and fund the care provided. We also spoke with four health care professionals to gather their feedback about the service.
We spoke with ten people who used the service, five relatives, the registered manager, the clinical lead who is also the deputy manager, the administrator, three members of staff, the cook, the cleaner, an agency nurse and the regional manager.
We looked at a range of documents and records related to people's care and the management of the service. We looked at four care plans, two staff recruitment records, one agency staff file, training records, quality assurance audits, minutes of staff and resident’s meetings, complaints records and policies and procedures.
Updated
23 August 2018
This comprehensive inspection took place on 18, 20 and 29 June 2018. The first day was unannounced. We told the service we would be visiting on the second and third day.
This is the first inspection of the service under a new provider and is rated Requires Improvement overall. This is the first time the service has been rated Requires Improvement.
At this inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to staffing and governance. You can see what action we told the provider to take at the back of the full version of the report.
Burley House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Burley House accommodates a maximum 22 people in one adapted building who require nursing or personal care and support with their mental health needs. At the time of our inspection there were 15 people living at the service.
The home had a registered manager. 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.
Staff were not receiving regular supervision and appropriate training to ensure they could meet the needs of people using the service.
The provider did not have a robust system to monitor the quality of service provided. Actions that had been identified were not followed up to ensure they had been completed. The provider had not consulted people about the quality of service.
The service held meetings to check people's health needs were met, but this lacked oversight from the provider. We have made a recommendation about the provider ensuring the registered manager is supported with the clinical governance of the service to ensure care and treatment is in line with current best practice guidelines.
There were positive interactions between people and staff. Staff knew people well and promoted their independence. Health care professionals were involved in supporting people to achieve good health outcomes; this included their nutrition, physical and mental health needs.
Care was person-centred and people were provided with choice. People told us they were happy and felt well cared for. Care records contained information about people's needs, preferences, likes and dislikes. Staff understood people were individuals and would not tolerate discrimination.
Medicines were administered safely and people told us they felt safe with the staff who supported them. Staff received training in how to safeguard people and understood what action they should take to protect people from abuse. Staff recorded accidents and incidents that occurred at the service to reduce the risk of reoccurrence. There were enough staff to meet people's needs and pre-employment checks were undertaken to ensure their suitability to work with people.
People were supported to make choices about their day to day lives and were supported by kind and caring staff who were committed to providing a good service. Staff asked people for their consent before offering support and treated people with dignity and respect. People were supported to have maximum choice and control of their lives and staff supported them in the least restrict way possible; the policies and systems in the service supported this practice.
People and their relatives told us they felt welcome at the service and felt able to raise any concerns with the registered manager or staff. The registered manager promoted an open and relaxed environment for both people using the service and staff.