Burley Hall Care Home

Updated 31 August 2019

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.

Inspection team

The first day was carried out by two inspectors 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 subsequent days were carried out by one inspector.

Service and service type

Burley Hall Care Home 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.

The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

The first two days of the inspection were unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with six people who used the service and seven relatives about their experience of the care provided. We spoke with eleven members of staff including the manager, three nurses, a unit manager, three senior care workers, a hostess, a care worker and the chef.

We reviewed a range of records. This included six people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with a professional who regularly visited the service.

Updated 31 August 2019

Burley Hall Care Home is a residential care home providing personal and nursing care to 38 people at the time of the inspection. The service can support up to 49 people. The home is split into two distinct units; Wharfedale and Greenholme. Both units accommodate people requiring a registered nurse to oversee their care. Greenholme specialises in providing care to people living with dementia.

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

Some improvements were required in how the service assessed and managed risk, as some risks were managed well, but others had not been identified to ensure the necessary control measures were in place. Medicine management procedures were in place. Staff were appropriately trained, and their competency levels checked.

Robust health and safety checks were in place and regulatory compliance was maintained. Up to date certificates were in place.

People told us they liked the food and were offered choice of food options. Records relating to what people had taken to drink were not always completed to show people were being supported to drink.

The home had referred people who had restrictions on their liberty to the relevant authorities. 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.

People and their relatives spoke highly of staff at the service who they described as caring and compassionate. They had concerns about the high number of temporary staff but were hopeful for a period of stability once new staff had started in post.

People were encouraged to participate in a range of different activities. Complaints were reviewed and responded to in line with company policy. Relatives told us the manager was responsive to informal complaints and they were confident in their willingness to improve care.

Staff were not consistently recording when they had met a person’s care needs, to keep an up to date record care had happened.

The manager was working with professionals, stakeholders and involving the local community to improve the experience of people living at the home.

Audits and checks were carried out; however, these were not always effective in identifying areas which needed to be improved. The provider had not notified CQC of significant events as required which showed an issue with the overview of 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

The last rating for this service was requires improvement (published 29 June 2018). This service has been rated requires improvement for the last two consecutive inspections. Prior to that inspection they had been rated as inadequate.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to good governance and failure to notify us of significant events.

Please see the action 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.