CQC report explained · a nursing home
What the CQC found at Burdon Grange Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risk records were incomplete, and medicines were not always stored or recorded safely. Staffing records also did not allow inspectors to confirm whether staffing was consistently safe or sufficient.
- Effective?
- Requires improvement
- People's needs were generally assessed and supported, but not all staff had training for the complex conditions present. There was also no effective record of staff supervision and appraisal.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people well and supported their choices, independence and contact with relatives.
- Responsive?
- Good
- Care plans were individualised and staff understood people's needs and communication preferences. People were supported with activities, relationships, complaints and end-of-life care.
- Well-led?
- Requires improvement
- The home had audits and a clear management structure, but its governance systems had not identified problems with care records, medicines, training, supervision and recruitment. Staff gave mixed views about communication and leadership.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found caring, responsive support but unsafe medicines practices, incomplete care records and weak oversight.
Inspectors visited on 22 June 2022. They spoke with people, relatives, staff and healthcare professionals. They observed care and checked care records, medicines, recruitment, safety checks, complaints and quality audits.
The home was caring and responsive. People were treated with dignity, staff knew them well, and care plans were person-centred. Families and healthcare professionals gave mainly positive feedback. Infection control arrangements were also found to be suitable.
There were important safety and management problems. Some medicines were not stored or recorded safely. Care records did not always contain enough detail about risks such as catheters, suction equipment, seizures and diabetes. Audits had not found these problems, and records of staff supervision and appraisal were not properly monitored.
The overall rating changed from Outstanding at the previous inspection to Requires Improvement. The home breached Regulation 12 on safe care and treatment and Regulation 17 on good governance. CQC asked for an action plan and said it would monitor progress.
Personalised support
Care plans were tailored to individuals. Staff knew people's histories, needs and communication preferences.
“Care plans were person centred, individualised and relevant to the person to whom they related.” from the report
Good partnership working
Healthcare professionals gave very positive feedback. The home worked with relevant professionals to support people's health and changing needs.
“The feedback we received from healthcare professionals who worked with the service was very positive.” from the report
Activities and family contact
People were supported to take part in activities inside and outside the home. Relatives were welcomed and supported to visit safely.
“People were supported to take part in activities both within the service and externally.” from the report
Medicines were not always managed safely
seriousSome medicines were not dated or stored safely. Variable doses and rescue medicines were not always supported by clear records or instructions.
“Variable dose recording did not always record the actual dose administered.” from the report
Risk information was incomplete
seriousSome care records lacked important guidance about equipment and conditions, including catheters, suction, seizures and diabetes. This created a risk that care might not match people's assessed needs.
“We found incomplete or sub-optimal records relating to the management of identified risk.” from the report
Audits did not find problems
seriousThe home's checks had not identified the concerns about care records, medicines, training, supervision and recruitment. This was linked to a breach of good governance.
“The current auditing systems had not identified that sub-optimal records in relation to clinical care or inaccurate recording and storage of medicines.” from the report
Staff support and communication varied
needs fixingSome staff wanted more training and said supervision was irregular. Staff also gave mixed views about communication and leadership.
“There was no record maintained to demonstrate oversight of when clinical and care staff received supervision or appraisal.” from the report
- 01What has been changed to ensure medicines are stored safely, dated after opening and accurately recorded, including variable and rescue medicines?
- 02How have care plans and risk assessments been updated for people using catheters, suction equipment or seizure and diabetes management?
- 03How do you now check that audits identify problems with medicines, care records and emergency evacuation information?
- 04How often do staff receive supervision, appraisal and training for conditions such as cerebral palsy, epilepsy and multiple sclerosis?
- 05What has been done to improve communication between managers and staff and to ensure staffing is sufficient on every shift?
This inspection looked at all five key questions, including medicines, care records, staffing, leadership and infection control; it was prompted partly by a serious incident, but CQC did not examine the circumstances of that incident. This explanation was written from the published report of 18 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2020
Rated Outstanding; inspectors found exceptionally caring and responsive support, with safe, effective and well-led care rated Good.
This was an unannounced inspection over 4 and 5 December 2019. One inspector spoke with 10 people and 11 staff, observed care, reviewed three care files and three staff files, and checked training, policies and other records. Feedback was also sought from three professionals and two relatives.
Inspectors found a strong person-centred culture. People were treated with kindness and respect, and staff understood their individual needs, preferences and communication methods. The home provided personalised activities, education, community trips and support to maintain relationships and independence.
People were found to be safe. Medicines, staffing, recruitment, infection control and risk management were satisfactory. Staff were trained and supported, health professionals were involved when needed, and audits were used to improve care.
The overall rating was Outstanding. Caring and Responsive improved from Good to Outstanding since the previous inspection, while Safe, Effective and Well-led remained Good. The previous overall rating was Good.
Kind and individual care
Staff treated people as individuals and built care around their wishes, beliefs and interests. Inspectors saw strong relationships and a warm, friendly atmosphere.
“There was a strong, visible person-centred culture, embedded at all levels.” from the report
Dignity and independence
The home used personalised equipment, communication methods and technology to help people express themselves and do more for themselves.
“Promoting people's independence through enhanced communication and technology was central to the service provided at Burdon Grange.” from the report
Activities and community life
People had many opportunities to learn, maintain relationships and take part in activities inside and outside the home. Staff adapted outings around people's health needs.
“There was an extensive range of activities on offer to people, with a dedicated activities team, so that activities could happen throughout the week.” from the report
Safe staffing and medicines
Staffing arrangements met people's needs, and inspectors found medicines were stored, administered and checked safely.
“Staffing arrangements met people's needs.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you tailor a care plan to my relative's communication methods, routines and personal interests?
- 02What activities, education and community outings would be available for my relative, and how would you adapt them if their health changed?
- 03How would you support my relative to maintain contact with family and friends?
- 04How do you check that medicines are given as prescribed and that staff remain competent to administer them?
- 05How do you involve families and professionals when my relative's health, capacity or care needs change?
This was an unannounced comprehensive inspection covering all five key questions, including the premises and care provided; the report also says the previous rating was Good. This explanation was written from the published report of 14 March 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Burdon Grange Care Home
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingdown from OutstandingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2020Outstandingup from GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Good
- June 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016
Registered with the Care Quality Commission on 1 June 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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17 live-in carers within about an hour of Devon
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
“She is such a warm and gentle person while being professional and competent at the same time.”
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.