CQC report explained · a nursing home
What the CQC found at Burnham Lodge Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had risk assessments, accessible call bells and emergency evacuation plans. Medicines records were checked and found to be accurate, although one bathroom had cracked tiles that could make cleaning and infection control more difficult.
- Effective?
- Good
- People's health, nutrition and specialist needs were monitored, with referrals to professionals when needed. Inspectors found some uncertainty about whether mental capacity assessments were specific to each decision.
- Caring?
- Good
- People described staff as respectful and positive. Inspectors saw people treated with kindness, dignity and respect, and involved in decisions about their care.
- Responsive?
- Good
- Care plans included people's preferences, interests, communication and health needs, and were reviewed regularly. Activities were available, and people were told how to complain.
- Well-led?
- Good
- The home had a registered manager, supportive senior staff and systems to check quality and safety. Staff reported good communication and felt able to raise concerns.
What inspectors found, May 2019
Burnham Lodge Nursing Home was rated Good overall; inspectors found kind, safe care, with some records and maintenance needing attention.
Inspectors visited on 11 April 2019 without giving notice. They spoke with seven people living in the home, a visitor and four staff. They reviewed care records, recruitment files, complaints and safety and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they were happy with the care. Inspectors saw respectful staff, a calm atmosphere and care plans that were regularly reviewed.
There were some smaller issues. Cracked bathroom tiles could make cleaning harder, and it was not always clear that separate mental capacity assessments had been completed for each decision. One staff vacancy was being recruited to.
The home had improved since the previous inspection in March 2018, when it was rated Requires Improvement. The report says legal requirements were met and that the service would continue to be monitored.
Kind and respectful care
People spoke positively about the care, and inspectors saw staff treating people respectfully and encouraging their independence.
“People were treated with kindness dignity and respect.” from the report
Up-to-date care planning
Care plans covered people's health, communication, mobility, nutrition, interests and personal history. They were reviewed regularly and people were involved.
“People's care was reviewed regularly so that care plans were up to date and reflective of people's current needs.” from the report
Good support for staff
Staff said their training, induction, supervision and support gave them the skills needed for their roles.
“Staff were positive about working at the home and told us they received good support and training to assist them in their roles.” from the report
Accurate medicines records
Inspectors found suitable medicine storage and checked a sample of administration records, which were completed accurately.
“We checked a sample of these and found them to be completed accurately.” from the report
Bathroom maintenance
needs fixingOne upstairs bathroom had cracked tiles. The home said it planned to refit the room as a wet room.
“We saw that in one of the upstairs bathroom, there were some issues such as cracked tiles which could potentially make cleaning and infection control more difficult.” from the report
Mental capacity records
needs fixingThe report says it was not clear that a separate capacity assessment had been completed for every decision made on behalf of a person.
“it wasn't clear that a specific capacity assessment had been undertaken for each decision made for a person” from the report
Staff vacancy
minorOne staff member had recently left and the home was recruiting to fill the post. Staff said staffing was generally sufficient, although it could be busy at times.
“one member of staff had recently left, and they were recruiting to this post but otherwise they were fully staffed.” from the report
- 01Has the upstairs bathroom been repaired or converted into the planned wet room?
- 02How do you now make sure there is a separate mental capacity assessment for each important decision?
- 03Has the vacant staff post been filled, and how do you maintain staffing levels when the home is busy?
- 04How are people's care plans and monthly reviews shared with them and their families?
- 05What activities and support are currently available for each person's social, emotional and spiritual needs?
This was a planned inspection covering all five key questions, although the visit itself was carried out without notice. This explanation was written from the published report of 29 May 2019 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, April 2018
Rated Requires Improvement; inspectors found safe and caring support, but legal decision-making, care planning, meals and quality checks still needed work.
This was an unannounced comprehensive inspection on 6 and 7 March 2018. Inspectors spoke with people, a visitor and staff, observed care, and checked care plans, medicine records, staff files, audits and other records.
The home was rated Good for Safe and Caring. People said they felt safe and were treated with kindness, dignity and respect. Staff understood people's risks, medicines were generally administered safely, and the home was clean.
The home was rated Requires Improvement for Effective, Responsive and Well-led. Inspectors found gaps in Mental Capacity Act records, limited choice and mixed experiences at mealtimes, incomplete planning for social and wellbeing needs, and quality checks that had not found every problem.
Improvements had been made since the August 2017 inspection, including in risk management, cleanliness and some medicines processes. However, some concerns remained from that inspection, despite an action plan saying improvements would be completed by January 2018.
People felt safe
People told inspectors they felt safe. Staff understood safeguarding and how to report concerns.
“People told us they felt safe at Burnham Lodge Nursing Home.” from the report
Kind and respectful care
Inspectors saw staff being kind, patient and respectful. People said staff protected their privacy and dignity.
“People were supported by staff that treated them with kindness, respect and compassion.” from the report
Health support
Staff monitored people's health and contacted health professionals when needed. Records showed appropriate referrals had been made.
“This meant people's healthcare needs were being met and they received on-going healthcare support.” from the report
End-of-life care
The home recorded people's wishes about end-of-life care and where they wanted to die. Inspectors found care could be compassionate and focused on comfort.
“People could be assured that at the end of their life they would receive care that was compassionate and ensured their comfort.” from the report
Decision-making records
needs fixingSome Mental Capacity Act assessments covered several decisions without clearly identifying the specific decision involved. The report recommends reviewing the guidance and practice.
“Some improvements were still required to ensure full compliance with the MCA.” from the report
Incomplete care plans
needs fixingPlans did not always explain people's social, emotional, spiritual and wellbeing needs or record whether planned support had been refused or provided.
“However, the care plans in relation to people's social, emotional and spiritual needs still required some improvement.” from the report
Quality checks missed problems
needs fixingAudits had improved but did not identify every issue. Inspectors still found inaccurate mattress settings, incomplete care plan details and gaps in Mental Capacity Act practice.
“This meant the systems in place to monitor and improve the quality and safety of the service were still not fully effective.” from the report
Mixed activity experience
minorActivities were available, but inspectors saw people sitting without meaningful engagement and some people could remain in the same position all day.
“Our observations of people engaging in meaningful activities and occupation during our inspection were mixed.” from the report
- 01How do you now make and record a separate Mental Capacity Act assessment for each important decision?
- 02How are residents offered a genuine choice of meals, drinks and condiments, including when they cannot easily ask for them?
- 03How do you make sure creams and lotions are applied as prescribed and recorded each time?
- 04How have care plans been updated to cover each person's social, emotional, spiritual and wellbeing needs?
- 05What checks now make sure pressure-relieving mattresses are set correctly and that audits find problems promptly?
This was a comprehensive inspection of the home, including care and premises, with all five key questions assessed; it also checked progress after the August 2017 and December 2017 inspections. This explanation was written from the published report of 11 April 2018 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 Burnham Lodge Nursing Home
4 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- May 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementstayed Requires improvementSafe: Inadequate
- November 2017Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015
Registered with the Care Quality Commission on 30 June 2015.
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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