CQC report explained · a residential care home
What the CQC found at Burlington Villa
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2022
Overall Requires Improvement, with Safe rated Inadequate; inspectors found unsafe medicines management and unnecessary restrictions on people's freedom.
This was an unannounced inspection on 20 June 2022. Two inspectors spoke with people, relatives and staff. They reviewed care records, medicine records, staff files and the home's management records.
The most serious concerns were about locked internal and external doors, restrictive practices and medicines. People could not freely access some bedrooms, bathrooms, the kitchen or communal areas. Medicine records and stock checks were incomplete or inaccurate.
Inspectors also found kind staff, good staff training, clean surroundings, healthcare support and activities. However, care plans, communication, involvement and quality checks were not always good enough. The overall rating was Requires Improvement. Safe fell from Good to Inadequate, while Effective, Caring, Responsive and Well-led fell to Requires Improvement.
Kind and familiar staff
Staff knew people's likes and dislikes and had generally stayed in post for several years. This gave people a more consistent approach.
“Staff turnover was very low, this gave people a more consistent approach from staff who knew them well.” from the report
Staff training
Staff had completed training relevant to supporting people with learning disabilities, autism and mental health needs. New staff, including agency staff, received an induction.
“Staff were appropriately trained and had completed training in autism and equality and diversity.” from the report
Healthcare support
People were referred to healthcare services when needed and were supported to attend appointments. Health professionals were involved in some people's care.
“People had access to healthcare professionals and were supported by staff to attend appointments.” from the report
Activities and community access
People were supported to go out, visit local places, attend events and make plans for future holidays.
“Staff encouraged people to go out into their community.” from the report
Clean and personalised home
The home was clean and well maintained. People could personalise their rooms and had access to a large outdoor area.
“The service gave people care and support in a safe, clean and well-maintained environment.” from the report
Locked doors and restrictive practice
seriousAll internal and external doors were locked because of one person's behaviour. This restricted other people's access to parts of their own home, without evidence that less restrictive options had been properly considered.
“This was not proportionate and deprived people unnecessarily of being able to freely move around their home.” from the report
Medicines were not safely managed
seriousMedicine balances were wrong, weekly checks were not completed, some reasons for as-required medicines were not recorded and medicine administration records had gaps. Medicines were also not always stored safely.
“We found no evidence people had been harmed, however medicines were not always safely managed. This placed people at risk of harm.” from the report
Behaviour support records
needs fixingBehaviour support plans did not always contain essential information, and staff did not consistently follow them. Records of incidents and the use of medicine or chemical restraint were not detailed or reviewed well enough.
“There was limited opportunity for staff to learn from incidents and improve practice.” from the report
Weak management checks
needs fixingAudits did not identify several problems found by inspectors, including medicine shortfalls and the restrictions caused by locked doors. Important incident information was not always added to care plans.
“Systems and process to monitor the service were not effective.” from the report
Information was not always accessible
needs fixingSome meeting minutes and other information were not in formats that everyone could understand. The home provided some easy-read documents after the inspection.
“Information was not always provided in formats people could understand.” from the report
- 01Which internal and external doors are still locked, and how can each person move freely around the home now?
- 02What checks are now made on medicine balances, storage and medicine administration records?
- 03How are as-required medicines and any chemical restraint recorded, reviewed and checked for effectiveness?
- 04How have behaviour support plans been updated, and how do you make sure staff follow them?
- 05What changes have been made to management audits so that safety and care shortfalls are found promptly?
This was an unannounced inspection covering all five key questions and infection prevention and control; the report compares the ratings with the previous inspection published in 2017. This explanation was written from the published report of 18 October 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, November 2017
Rated Good overall, with Outstanding caring; inspectors found kind, personalised support and a few monitoring issues that were addressed after the visit.
The inspection was unannounced and took place on 14 September 2017. Two inspectors and an expert by experience spoke with people living at the home, relatives, staff and the manager. They also checked care records, medicines records, recruitment files, training information, rotas, complaints and quality checks.
The home supported up to nine people with a learning disability. All nine places were in use on the inspection day. Inspectors found people were safe, had enough staff and received their medicines safely. Staff had the training and support needed, and people were supported with food, drink, healthcare and decisions about their care.
Caring was rated Outstanding. Inspectors saw very warm relationships, respect for privacy and dignity, and detailed support for communication, culture, routines and independence. Responsive and well-led were rated Good, with personalised care plans, activities, complaints arrangements and quality checks in place.
The overall rating remained Good, as it had been at the August 2015 inspection. The rating for caring improved from Good to Outstanding. Inspectors identified some issues with monitoring health and fluid intake, and an unsecured wardrobe, but the report says action was taken or promised.
Exceptionally caring staff
Inspectors saw many warm and positive interactions. Staff treated people with dignity and built trusting relationships.
“We observed a huge number of positive, warm and loving interactions between staff and people during our visit.” from the report
Personalised communication
Staff understood different ways people communicated and adapted their approach so people could express their views and make choices.
“Staff had an excellent understanding of how people communicated and used this to maximise people's decision making ability and facilitate involvement and choice.” from the report
Support for independence
People were helped to develop skills, take part in activities and work towards more independent living.
“People were supported to be as independent as possible and this had a positive impact on people's lives.” from the report
Safe medicines arrangements
Inspectors found staff training and checks for ordering, storing and giving medicines were effective and safe.
“Records confirmed staff had received appropriate training and the checks completed on the ordering, storage, administration and auditing of medicines were found to be effective and safe.” from the report
Strong leadership
The home had an open culture where people and staff could raise concerns. Quality checks were carried out regularly.
“The registered manager had systems and processes in place to monitor the quality and safety of the service” from the report
Fluid intake was not monitored robustly
needs fixingInspectors found that one person's fluid intake was not being monitored properly. The manager took action after the inspection.
“The same person needed their fluid intake monitoring and we saw this was not being monitored in a robust way.” from the report
Health monitoring needed improvement
needs fixingInspectors found that monitoring of one person's health condition needed to improve. The manager addressed this after the visit.
“Improvements were needed to ensure effective monitoring of a health condition for one person.” from the report
Unsecured bedroom furniture
minorA wardrobe in one bedroom was not secured to the wall and could have posed a risk. The manager said this would be addressed.
“We saw a wardrobe in one person's bedroom was not secured to the wall which could pose a risk to the person.” from the report
- 01How do you now monitor fluid intake for people who need it?
- 02What changes were made to monitor the health condition identified in the report?
- 03Was the unsecured wardrobe fixed, and how are bedroom safety checks recorded?
- 04How do you make sure staff understand each person's communication method, routines and anxieties?
- 05What has changed at the home since this 2017 inspection?
This was a comprehensive inspection covering all five CQC questions and included discussions with people, relatives and staff, and checks of care, medicines, staffing and quality records. This explanation was written from the published report of 1 November 2017 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 Burlington Villa
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
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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