Archived: Burgess Park

Updated 27 April 2017

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 inspection took place on 23 and 31 January 2017and was unannounced. We carried out this inspection over two days. On day one, two inspectors, an inspection manager and an Expert by Experience carried out this inspection. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. On day two, three inspectors carried out the inspection

Before the inspection, we looked at information we held about the service, including notifications we received. We also reviewed the action plan we received about the service on how they intended to improve the service. During the inspection we spoke with 16 people five relatives, the regional manager, the manager and two resident experience managers who were providing additional management support to the interim manager. We also spoke with two nurses, seven care workers, a visiting health care professional, and the maintenance worker.

We used general observations and 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. We also observed people in the communal areas and the general environment of the service.

We reviewed 10 care records, 10 staff records, audits, health and safety records and other records for the management and maintenance of the service.

After the inspection, we contacted five health care professionals, commissioning and safeguarding officers from the local authority.

Updated 27 April 2017

Burgess Park is a nursing home that provides accommodation and personal care for up to 60 people, some of whom are frail and live with dementia. At the time of the inspection there were 31 people living at the service.

We carried out a comprehensive inspection at this service on 17 December 2015, and rated it as requires improvement. At that time we found two breaches in regulations for safe care and treatment and good governance. We asked the registered provider to send us a plan to tell us what they would do to meet legal requirements. We did not receive the action plan.

We carried out a focussed inspection on the 13 September 2016. We did not look at all of the Key Lines of Enquiry under each key question. We followed up on the breaches of regulations to see if the registered provider had made improvements to the service. At the last inspection on December 2015 we asked the provider to take action to make improvements for safe care and treatment and good governance. We found for safe care and treatment this action has been completed. However, we found the provider was in continued breach of good governance. We also found new breaches of staffing and person centred care. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. You can read the report from our last inspection, by selecting the 'all reports' link for Burgess Park on our website at www.cqc.org.uk.

This comprehensive inspection was carried out on 23 and 31 January 2017 to check that the registered provider had followed their plan and to check that they now met the regulations inspected. During this inspection, we found evidence that the provider had made some improvements. We found that the breach in relation to staffing was now met. We found a continued breach of good governance. We also found new breaches of safe care and treatment and need for consent. We found that further action is required to meet all the regulations we inspected.

There was no registered manager in post. 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. The registered provider was recruiting for a home manager. There is an interim manager at Burgess Park supporting the service whilst a permanent manager is recruited.

People did not receive safe care and treatment that met their needs because staff had not acted to manage them. People's health conditions were not managed well and they were at risk from deterioration of their health. Staff had not always followed health care professional’s advice and recommendations to manage people’s health needs effectively.

People did not have their medicines provided to them in a safe way. We found examples where staff did not administer medicines to people a way that helped maintain their health.

The quality assurance systems in place did not identify the areas of concern we found. The provider’s governance systems and audit systems were not always well organised. People did not receive safe quality care because the governance systems did not identify any concerns with the service.

People and their relatives, gave feedback to the provider about the quality of care they received. However, we found that the quality of care experienced did not match our findings at the inspection.

Assessment identified people’s care and support needs. These were completed with people and their relative. A plan of care was developed in order to provide guidance for staff to meet those assessed needs. However we found that reassessments of people’s needs did not take into consideration new health needs. Risks to people’s health and well-being were not always identified and used to plan their care.

Activities for people did not always meet their preferences or hobbies. The activities provided did not meet the needs of people with dementia or people who do not have English as their first language.

Consent to care was not always obtained by staff. Staff did not have an understanding of how to apply the principles of the Mental Capacity Act 2005 (MCA) to support people effectively in a way that was safe. People are not supported to have maximum choice and control of their lives.

People told us that staff showed them compassion and respect when supporting them. People and staff engaged and knew each other well. We found that staff did not always treat people with dignity in the provision of care.

There was sufficient staff to meet people’s care and support needs. The manager followed the registered provider’s staffing planning tool using the staffing level as recommended.

Training, supervision, and appraisals supported staff in their jobs. Resident experience managers supported staff through identifying their strengths, and to support them with their professional needs.

Food and drink provided met people’s needs and preferences. People told us they enjoyed their meals and they were able to choose meals they wanted from the menu provided.

There was a complaint process in place. This enabled people to make a complaint about an aspect of their care and support needs. People were aware of the process to follow if they wanted to raise a complaint. People and relatives we spoke with shared with us varied views of the service and the care they received.

Staff received support from the manager, the regional manager and three of the provider’s managers who currently provide leadership and management support at the service. Staff told us that the manager was open and transparent. The manager provided opportunities for staff to speak with them and have their concerns listened.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This is because the service is Inadequate in two key questions.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to be providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

This service has now remained in Special Measures for over 12 months. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. CQC is considering the appropriate regulatory response to resolve the problems. We will report on action we have taken in respect of this when it is complete. If the service has demonstrated improvements when we inspect it and it is no longer rate as inadequate for any of the five key questions it will no longer be in special measures.