Burdon Grange Care Home

Updated 18 August 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 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

This inspection was carried out by two Inspectors, a member of our medicines optimisation team and a specialist nurse adviser.

Service and service type

Burdon Grange Care Home 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. Burdon Grange is a care home with 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.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave a short period notice of the inspection because of recent tragic events involving people using the service. This had impacted on the health and well-being of both people using the service and staff. We wanted to ensure our visit was communicated to the provider to allow them to advise people and staff we would be attending and in what capacity.

What we did before the 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. We also reviewed additional information we held about the service, this included previous inspection reports and statutory notifications. A statutory notification contains information about certain incidents and events the provider is required to notify us about by law.

During the inspection

We spoke with seven members of staff which included the registered manager, clinical staff, care staff, activities staff and administrative staff. We also spoke with the Nominated Individual who was also the registered provider of the service. We spoke with seven people who lived at the service and observed interactions between people and staff.

We met with four people’s relatives and spoke with one visiting professional. We reviewed a range of records, including peoples’ care records, staff recruitment files, records relating to safety checks including fire safety, complaints records and accident and incident records. We also reviewed medicines records and records relating to monitoring and quality assurance.

Following our site visit we spoke with an additional 10 staff members. We contacted five healthcare professionals to seek their views on the service and received feedback from four of them. We also received further clarification and documentation from the service to validate evidence found.

Updated 18 August 2022

About the service

Burdon Grange Care Home is a nursing home in one adapted building that provides accommodation for people who require nursing and personal care. There is also a separate flat that provides accommodation for two people. The service is registered to accommodate up to 31 people who have complex physical and nursing needs. At the time of our inspection there were 26 people using the service.

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

Not all risks in relation to the management of medicines were managed safely and we found omissions in some clinical records that may expose people to risk. Some medicines were not being stored safely and variable dose medication was not accurately recorded. The providers current policy was not comprehensive in some areas.

The current governance systems in operation had not identified the areas of concern we found during the inspection. Whilst it was not evident this had resulted in impact or harm to people, people were at risk of not receiving care in line with their assessed needs.

Not all staff were positive about the leadership of the service. Some staff told us they felt communication from the registered manager could be improved and that this would make a positive difference to the people they supported and increase team cohesion.

People were well supported by staff that were caring and treated them with dignity and respect. Staff knew people well and understood their needs. We received positive feedback from people and their relatives during the inspection.

Risks of abuse to people were minimised. Staff had received safeguarding training and the service had appropriate safeguarding systems and processes. Staff understood safeguarding reporting processes. There were effective systems that ensured the service and environment were safe. Health and safety checks, together with effective checks of the environment were completed.

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. There were systems in place that ensured people who were deprived of their liberty were done so with the appropriate legal authority.

People were supported by staff who had the skills and knowledge to meet their needs, however some staff told us they would like a more comprehensive continual training package. There was no effective system to monitor staff supervision and appraisal and not all staff were positive about the support they received.

There was a system to investigate and respond to peoples’ concerns and complaints. People and their relatives commented positively about the registered manager and the quality of care their family member received. No concerns were raised about the quality of care provided.

The service continually looked to learn and improve care provision for people. They were involved in trials of new systems and methods to improve peoples’ lives. The service worked well with other professionals and we received very positive feedback from healthcare professionals we contacted about both the care provided and the standard of leadership at the service.

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 Outstanding (published 14 March 2020).

Why we inspected

The inspection was prompted in part by notification of a specific incident as a result of which two people using the service died and another was seriously injured. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. The information CQC received about the incident indicated concerns about the management and assessment of risk. This inspection examined those risks.

We also 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.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance.

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

The overall rating for the service has changed from Outstanding to Requires Improvement based on the findings of this inspection.

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.