What the CQC found at Burnham Lodge

Inspectors found appropriate recruitment checks, including identity checks, references and disclosure and barring checks. Induction and supervision were also in place.

“Safe recruitment procedures were in place. Staff completed an application form, attended for interview and preemployment checks were carried out.” from the report

Inspectors observed a nurse checking records, labels, stock and consent before giving oral medicines. Oral medicines were administered by nurses whose competence had been assessed.

“The nurse checked the medicine administration record (MAR), cross referenced with the medicine label, and stock checked each medicine before administration.” from the report

The home analysed falls and introduced actions such as better use of sensors and supervision. Records showed falls reduced by about 45% between July and September 2021.

“Records showed an overall reduction of around 45 percent in the number of falls between July 2021 and September 2021, indicating some actions had been effective in reducing the amount of falls.” from the report

Professionals said the home generally worked well with the GP, tissue viability nurses and other services. They said advice was followed and contact was timely when concerns arose.

“When Burnham Lodge have concerns, they do contact in a timely manner, [are] welcoming, follow our advice and do everything they can in patients' best interest to heal or palliate [the] wound as required.” from the report

Some care plans lacked accurate, personalised information about behaviours, diabetes, allergies, thickened fluids and falls. Inspectors said this increased the risk of harm.

“Risks to people were not clearly identified and managed. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report

Thickeners and creams were not always stored safely. Cream instructions were incomplete or out of date, and medicines fridge temperature problems were not always followed up as required.

“We found evidence safe medicine practices were not promoted in relation to medicines storage and use of topical medicines.” from the report

People's temperatures were not consistently checked twice a day, including during isolation after hospital discharge. This was a breach of the safe care and treatment regulation.

“Effective systems were not operated to assess people's temperatures twice daily to check for signs of COVID-19 infection, including people isolating on admission.” from the report

Some potential safeguarding incidents and other events were not reported to the local authority or CQC within the required arrangements. The home submitted the outstanding notifications after inspectors raised the issue.

“Effective systems were not in place to identify or report incidents to CQC in accordance with requirements.” from the report

Several relatives described difficulty getting through by telephone and receiving updates. Some people and relatives also reported frequent changes in care staff and delays when help was needed.

“Communication with relatives is a weak point…I had a call to say dad had fallen out of bed, but it was two days previous…I can ring all day and get no answer” from the report

Inspectors saw kind and respectful care, but also staff entering rooms without knocking, limited interaction and delays responding to a person's request. Daily records contained limited information about activities and enjoyment.

“We found some interactions did not promote a person-centred culture.” from the report