CQC report explained · a residential care home
What the CQC found at Burnside Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found kind care, but serious weaknesses in safety, consent, records and management.
This was a focused inspection on 14 March and 4 April 2022. Inspectors spoke with people, relatives, staff and managers, observed care, and checked care, medicines, recruitment and quality records.
People and relatives who shared their views were generally happy with the care. Staff were described as kind and prompt. The home was clean, meals were well liked, and people were supported by staff who knew them.
However, inspectors found risks were not always identified or managed. Examples included incorrectly set pressure mattresses, missing safety checks, incomplete food and fluid records, unsafe recruitment records, gaps in medicines records and poor infection control practice.
The home was rated Requires Improvement overall, and for Safe, Effective and Well-led. It had received this rating for three consecutive inspections. Caring and Responsive were not assessed in this focused inspection, so their previous ratings were carried forward.
Kind and familiar staff
People and relatives described staff as kind, attentive and unhurried. Staff knew people's needs and usually responded promptly.
“People were supported by a regular team of care staff who knew them and their needs well.” from the report
People felt safe
People who could share their views said they felt safe and happy. Relatives also expressed confidence in the staff.
“People who were able to share their views with us, told us they felt safe and were happy living at Burnside Court.” from the report
Food and drink
People liked the meals and had choices. Staff knew people's dietary needs and preferences, although records for some people at risk of malnutrition were not good enough.
“People told us they liked the meals provided, they had plenty to eat and a good choice of food.” from the report
Training and staff support
Staff had training in several relevant areas and received supervision and competency checks. Some induction records were incomplete.
“People were supported by staff who had received training to help ensure they could meet people's needs safely and effectively.” from the report
Family involvement
People, relatives and staff were invited to give feedback. Relatives said they were listened to and could visit regularly.
“Records showed people, relatives and staff were invited to share their views about the home at residents' meetings and through the use of questionnaires.” from the report
Risks were not managed
seriousSome pressure mattresses were set incorrectly, safety checks had stopped, and recorded high water temperatures were not acted on. This increased the risk of avoidable harm.
“The failure to effectively manage and mitigate risks placed people at an increased risk of harm.” from the report
Consent and restrictions
seriousMental Capacity Act assessments and best-interest decisions were poorly completed. Staff did not always recognise restrictions such as bedrails or follow the correct process.
“The failure to properly assess and record people's capacity and best interest decisions risked compromising people's rights.” from the report
Incomplete care records
needs fixingCare plans, risk assessments and food and fluid records were not always complete or updated. This meant managers could not be sure that care was being delivered safely.
“Records were not always accurate and had not always been updated to reflect changes in people's needs.” from the report
Infection control practice
seriousInspectors saw masks being handled unsafely and staff were not challenged about this. Infection control audits were also not taking place.
“We were not assured that staff were using PPE effectively and safely.” from the report
Medicines records
needs fixingSome medicines instructions did not contain enough information, and staff did not always record administration times. Medicines audits had not been completed since November 2021.
“Staff did not always record the time of administration, so could not be sure of a safe gap between doses.” from the report
Recruitment checks
seriousTwo staff files did not contain complete work histories, and one previous employment reference had not been followed up.
“The failure to establish and operate safe and effective recruitment procedures is a breach of Regulation 19” from the report
- 01What has been done to make sure every pressure mattress is set correctly and checked every day?
- 02How are fire, water temperature, window restriction and other environmental safety checks now recorded and reviewed?
- 03How do you assess capacity, record best-interest decisions and obtain consent for restrictions such as bedrails?
- 04How are food and fluid intake records checked for people at risk of malnutrition, and when are healthcare referrals made?
- 05What changes have been made to medicines audits, recruitment checks and governance since the warning notice?
This was a focused inspection of Safe, Effective and Well-led, including infection control; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 21 May 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 Requires Improvement; inspectors found safe, kind care, but legal consent and quality checks were not reliable enough.
The inspection was unannounced and took place on 19 and 20 February 2020. The inspector spoke with people living in the home, relatives and staff, and checked care, medicines, recruitment and management records.
People generally felt safe and said staff were kind. There were enough staff, medicines were managed safely, the home was clean, and people received support with food, activities and healthcare.
The home did not always follow the Mental Capacity Act when making decisions for people who might lack capacity. Records did not always show that people were involved or that decisions were in their best interests and the least restrictive option.
The overall rating remains Requires Improvement. Safe improved from Requires Improvement to Good. Effective fell from Good to Requires Improvement, while Caring and Responsive stayed Good. Well-led remained Requires Improvement.
Enough staff
People and relatives said there were enough staff, and inspectors' observations supported this. Staff recruitment checks were also carried out.
“People and relatives told us, and our observations confirmed, there were enough staff deployed to ensure people's needs were met.” from the report
Safe medicines
Medicines were given by trained staff and records showed they were usually given as prescribed. There were procedures for ordering, storing, administering and recording medicines.
“There were safe procedures to ensure medicines were correctly ordered, stored, given and recorded.” from the report
Kind and respectful care
People described staff as kind. Inspectors saw warm relationships and found that privacy, dignity and independence were supported.
“People received care from staff who developed positive, caring and compassionate relationships with them.” from the report
Activities and relationships
People took part in activities and meaningful conversations. Staff also supported people to keep in touch with family and friends.
“We observed many social interactions including staff reading to people, playing individual and group games, and dancing and singing with people.” from the report
Consent and best-interest decisions
seriousThe home did not consistently follow the Mental Capacity Act. Records did not always show that people had been involved in decisions or that less restrictive options had been considered.
“The provider had failed to ensure the rights of people living in the home were upheld under the principles of the Mental Capacity Act 2005.” from the report
Quality checks missed problems
seriousThe home's monitoring systems failed to identify the consent failures and gaps in care plans. This was a continued breach of the good governance regulation.
“The provider and management had systems in place for monitoring quality of the service. However, governance systems and processes were not sufficient” from the report
Care plans lacked detail
needs fixingSome care plans did not fully explain people's health needs, preferences or how staff should provide support. Inspectors gave an example involving stoma care.
“Care records did not provide staff with instruction about how to help this person or contain any information about good practice, infection control or how to recognise concerns.” from the report
Some health information needed more detail
needs fixingInformation about particular health risks was not always detailed enough to ensure staff had the guidance needed to keep people safe.
“We found information associated with particular health risks, would benefit from more detail to ensure staff have sufficient information to keep people safe, for example, in relation to diabetes.” from the report
- 01How do you now record people's consent and best-interest decisions for sensor mats and CCTV?
- 02What checks make sure decisions are the least restrictive option for each person?
- 03How have you improved care plans so they include detailed guidance about health conditions such as diabetes and stoma care?
- 04What action did you report to CQC after the breaches of Regulations 11 and 17?
- 05How do your current quality checks identify missing consent records and gaps in care plans?
This was an unannounced planned inspection covering all five key questions; it followed the previous Requires Improvement rating and checked both the premises and care provided. This explanation was written from the published report of 28 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 Burnside Court
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2020Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 4 November 2010.
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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21 live-in carers within about an hour of Torbay
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 £980 to £1,400 a week. 17 can care for a couple. 12 years' experience on average.
“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.”
“She was not phased by anything, she was adaptable, kind & gave us complete confidence to go away & not worry about a thing!”
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.