What the CQC found at Buckingham House

Inspectors saw some kind interactions, including staff speaking with people by name and helping them enjoy an activity. This was not consistent across the home.

“We did see some positive interactions from staff and when they were providing care to an individual they treated them with respect, although this was at times inconsistent.” from the report

There were organised activities and staff specifically employed to try to involve people. Inspectors also saw adapted communication tools used with some people.

“There were opportunities for people to engage in organised activities and the staff, employed specifically for activities, tried to engage people in these activities.” from the report

The home had a complaints policy and inspectors found evidence that complaints were responded to and discussed with staff for learning.

“The provider had a complaints policy and we could see that complaints were responded to and responses also indicated that findings were discussed with staff in relation to lessons learned.” from the report

The home had a system for tracking applications and renewals where people were deprived of their liberty under the relevant safeguards.

“Applications were made to the relevant authorities to deprive people of their liberty, and there was a system to track and identify when a DoLS needed to be renewed.” from the report

Risks to people's health and safety were not reliably identified or reduced. Inspectors found missing risk plans, unsafe premises, poor fire safety and weak infection control.

“People did not receive safe care and treatment. Risks and care needs were not always identified and actions to lessen risks not taken.” from the report

Some people missed prescribed medicines because stock was not managed. Inspectors also found an unattended medicines trolley that people could access.

“People did not always receive their medicines in line with their prescribed needs.” from the report

Instructions from health professionals were not always carried out or recorded. This included concerns about breathing, COVID testing, suitable equipment and wound care.

“Clinical instruction in response to concerns being shared with health professionals was not followed.” from the report

Staff had not received fire safety training and could not clearly explain how they would evacuate people with complex moving and handling needs. The fire service later served an enforcement notice.

“A subsequent inspection by the fire service has found concerns and has served a fire enforcement notice on the service with a list of actions that require urgent attention by the service to make it safe.” from the report

Important information about people's needs, choices, self-harm risks, eating and drinking, and end of life wishes was missing from some records.

“People's care records were not always person centred.” from the report

Audits and checks failed to identify major problems. Inspectors found poor communication, inaccurate records and no effective overall view of staff competence and risks.

“The provider's systems and processes had failed to robustly assess, monitor and improve the quality and safety of the services and assess, monitor and reduce the risks relating to the health, safety and welfare of service users.” from the report