Burlington Villa

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People and those important to them were supported to understand safeguarding and how to raise concerns when they didn’t feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. When concerns had been raised, managers reported these promptly to the relevant agencies and worked proactively with them, to make sure timely action was taken to safeguard people from further risk. Safety risks to people were managed well. Managers assessed and reviewed safety risks to people and made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. Some improvements were needed to Health Action Plans, to ensure that people’s health needs were safely met. The management team were aware and working on this. There were enough staff to support people with their needs. Managers reviewed staffing levels regularly to make sure there were always enough suitably skilled and experienced staff on duty. Staff received relevant training to meet the range of people’s needs at the service.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a clear review of incidents that occurred at the service. This meant improvements could be made to people’s experiences. One person explained that staff always supported them to stay safe.

The management team had good oversight of what was happening at the service. They identified that there had been some concerns at Burlington Villa. However, they had clearly recorded these concerns and planned actions to make improvements. The management team had a good understanding of this document and what risks had been identified and prioritised. Where remaining improvements were needed to the service; these required actions were already planned.

Systems were in place to review incidents that had occurred and make improvements. Staff had clear guidance on how to record incidents, and we saw that this had resulted in clear record keeping.

The Department of Health has recommended that people with learning disabilities should be supported with a health action plan. This is a document, which describes how the person can be supported to remain healthy. The service had health action plans in place for each person. We identified that some of these health action plans did not include enough detail. For example, one person’s action plan described that they did not like going to the dentist. However, there was a lack of detail on how best to support their oral health. The management team had already identified this and were working to make the remaining improvements. People had clear summaries on how best they would be supported in a hospital setting. This portable documentation was called a ‘hospital passport’ and went with the person to any hospital appointments, to ensure they received appropriate care.

While documentation was not always fully detailed, staff and leaders had good knowledge of how to support people to remain healthy.

Documentation showed that people were supported to access health appointments. The positive outcomes of these appointments were clearly recorded.

There were clear policies in place to guide staff on how to respond to allegations of abuse. Where concerns were raised, we saw action had been taken to investigate. For example, a person’s balance of money was lower than expected. The management team were investigating whether this was due to poor record keeping or whether the money was unaccounted for. While this investigation was occurring, improvements had been made to how people’s incoming and outgoing money was recorded. At the last inspection, we found there were locks on people’s doors and unnecessary restrictions on how people lived. We saw this practice had stopped, and people’s human rights were supported.

People told us that they felt safe. They were aware who the manager was to report any concerns to.

All staff told us they had no concerns about abuse at the service. However, if they did; they knew how to report their concerns to their management team. All staff were confident that their concerns would be listened to and acted on, but also felt confident to report to external professionals by whistleblowing procedures if needed.

We saw staff and people had a positive relationship. So, we had no concerns about an abusive culture at the service. For example, one person had been out for the day, when they returned, they ran up to a staff member and were excited to show them the crafts they had made. Another person apologised to a staff member and they had a conversation about how they had done nothing that needed apologising for.

People were involved with managing risks. For example, there was a communal noticeboard where people could feedback what they wanted from the service, and action was taken to make improvements. The management team had reviewed records and noted that people were not always consulted in the writing of their care plans. We saw action was now being taken to include people in the writing of their risk assessments.

Care plans were in place to guide staff on how best to support people. Some care plans required more detail; however, the management team had already identified this in their service improvement plan. They were working to make these remaining improvements.

Staff told us that care plans provided enough guidance to keep people safe. Staff had a good understanding of people’s needs and how best to support them. For example, one person could become upset at the word ‘Please’. Staff knew how to communicate in a kind way without causing anxiety for the person. The management team explained that they were regularly reviewing care plans to ensure they provided the necessary detail for staff.

We saw that people were supported by staff that knew their needs well and supported them in a safe way.

Staff understood how to keep the environment clean. For example, a domestic staff member understood the expectations to keep the home clean and in line with current standards.

We saw the care home was well maintained.

There were clear processes in place to keep the environment safe. For example, the service had a fire risk assessment and did regular checks on the fire safety of the home. There were plans on how to evacuate people from the home safely if needed, and drills were in place to test the effectiveness of these plans. For example, one person was sensitive to loud noise. However, the plan described that when the fire alarm drill had occurred the person had engaged well with evacuating the building.

There were enough staff to support people safely. The management team had reviewed staffing levels and felt that an additional staff member would give staff additional time with people. They advised that action was underway to recruit this staff member. Multiple people at the service needed a staff member with them on ‘one to one care’. It was not clear in people’s care plans how this support should be offered. For example, how close the staff member was expected to be to the person, how often the staff member should be changed, how the person was involved in choosing which staff member supports them that day, or how the person was offered privacy.

People told us there were enough staff to support them. People felt staff were well trained.

Some people at the service needed a staff member with them at all times. We saw that staff members were clearly allocated to stay with the person as needed.

Two staff told us there were enough staff. Another staff member explained that staffing levels could be improved, as when staff cook meals this can cause reduced support for people. The management team explained that they recognised the need for an additional staff member and were in the process of recruiting for this role. Staff told us that they felt training was good quality. On the whole, staff had good knowledge of how to support people. We did identify that two staff had poor knowledge on ‘Deprivation of liberty Safeguards’ and how these legal safeguards impacted the people that lived at Burlington Villa. We reported this concern to the management team, who explained they would review staff knowledge and training in this area.

Staff had good knowledge of how to keep the service clean. The management team had good oversight of the infection prevention processes in place.

We saw the environment was managed safely to prevent the spread of infection at the service. Staff had access to personal protective equipment (like gloves) to ensure support was offered in a clean way that prevented the spread of infection.

There were clear processes in place to ensure the environment was kept clean. Records were kept by staff to show which rooms were cleaned and when. Processes kept people safe from the spread of infection. Legionnaires is a severe lung condition caused by inhaling legionella bacteria. There were clear processes in place to ensure this legionella bacteria did not build up in the water system. This kept people safe from developing this lung condition.

People were involved with making decisions about their medicines. One person said, “I get the medicine at the same time each day and they tell me what I am getting.” We saw that staff followed safe procedures when administering medicines.

Staff had good knowledge of how to manage medicines. One staff member said ‘Medicines are always locked away so they are safe. We write our initials when we give medicines, so it’s clear who has been responsible. At the end of the shift, we calculate how much stock left. So we know the correct medicine has been given out. So there is good oversight of stock levels now.”

There were clear processes in place on how staff should support people’s medicine needs. Concerns with medicines that were identified at the last inspection had been resolved. The current manager had identified that some further improvements were needed and had made changes to their pharmacy documentation to allow this. This new system had not yet been embedded at the service so we were unable to assess the impact of this change.