Burnside Court

Updated 21 May 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 team was made up of one inspector and an Expert by Experience who had consent to phone and gain feedback on the care provided by the service from people’s relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Burnside Court 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

The first day of the inspection was unannounced.

What we did before the inspection

Before the inspection we reviewed information we held about the service, including notifications we had received. Notifications are changes, events or incidents the provider is legally required to tell us about within required timescales. We also used information gathered as part of monitoring activity that took place on 11 February 2022 to help plan the inspection and inform our judgements.

We sought feedback from the local authority and 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 used this information to plan the inspection and took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spent time with and spoke with six people living at the service, 12 relatives, five staff members and the registered manager. Some people living at the service were unable to talk with us. We used the principles of the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. To help us assess and understand how people's care needs were being met we reviewed four people's care records. We also reviewed a number of records relating to the running of the service. These included staff recruitment and training records, medicine records and records associated with the provider's quality assurance systems.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at care plans, training data and quality assurance records and spoke with a representative from Torbay Council.

Updated 21 May 2022

About the service

Burnside Court is a 'care home' that provides care and support for a maximum of 26 older people, some of whom may be living with a dementia and/or physical frailty. At the time of the inspection 24 people were living at the service.

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

Although people who were able to share their views with us told us they were happy living at Burnside Court, and relatives we spoke with did not raise any concerns about the quality of care provided.

We found the service was not always operating in accordance with the regulations and best practice guidance. This meant people were at risk of not receiving care and support that promoted their wellbeing and protected them from harm.

Key pieces of information relating to people's care and support needs were not always being recorded or followed up.

People were not always protected from the risk of avoidable harm. We found where some risks had been identified, enough action had not always been taken to mitigate those risks and keep people safe.

People were not always protected from the risk and spread of infection.

People were not always protected by safe recruitment procedures.

People were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible and in their best interests.

Systems and processes to monitor the service were not undertaken robustly. This meant they were not always effective; did not drive improvement; did not identify the issues we found at this inspection and could not be relied upon as a source to measure quality and risk.

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 27th March 2020). Following that inspection, the provider was asked to complete an action plan to show what they would do and by when to improve. This was not received by the Commission .

At this inspection we found not enough improvement had been made and the provider remained in breach of regulations. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was part prompted by a review of the information we held about this service. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe, Effective and Well-led which contain those requirements.

We 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.

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 based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Burnside Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 safe care and treatment, infection prevention and control, need for consent, recruitment and governance at this inspection. We have also made recommendations in relation to management of people’s medicines and staff induction processes. Please see the actions 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.