CQC report explained · a nursing home
What the CQC found at Burrswood Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Burrswood Care Home was rated Inadequate in all areas and placed in special measures because people were at risk of harm.
Inspectors carried out an unannounced inspection over four dates. They spoke with residents, relatives and staff, observed care, and checked medicines, care plans, training and safety records.
They found serious problems across the home. Medicines were not managed safely, incidents and falls were not dealt with properly, staffing was disorganised, and infection controls were weak. Food choices and nutrition were poor, and some religious and cultural preferences were ignored.
Inspectors also found people were not always treated with dignity or supported in a person-centred way. Activities were very limited. Leadership, record keeping and quality checks had failed to identify or deal with the problems.
All five areas were rated Inadequate. The previous rating was Requires Improvement, published in September 2022. The home was placed in special measures because of the serious concerns.
End of life support
People nearing the end of life were supported to remain in the home where possible, with relevant healthcare professionals involved when appropriate.
“People nearing the end of life were supported to remain in the home wherever possible.” from the report
Recruitment checks
The required pre-employment checks, including Disclosure and Barring Service checks, had been completed for staff reviewed.
“Relevant pre-employment checks were completed, including with the Disclosure and Barring Service (DBS).” from the report
Some caring staff
Inspectors saw that some staff were caring and well intentioned, although this was not consistent across the home.
“Whilst it was evident some staff were caring and well intentioned, for others, they appeared indifferent and disinterested.” from the report
Unsafe medicines
seriousMedicines could not always be accounted for or given as prescribed. Some doses were delayed or unavailable, and some night medicines were given at teatime because trained staff were not available.
“Medicines were not managed safely which placed people at risk of harm.” from the report
Poor response to risks
seriousFalls and other incidents were not properly assessed or acted on. Safeguarding referrals were missed, and inspectors saw a person left distressed in a dining room as a restrictive practice.
“Management of witnessed and unwitnessed incidents, including falls, was not safe.” from the report
Disorganised staffing
seriousStaff deployment was frequently chaotic, especially on one unit. Staff followed routines based on tasks and times rather than people's needs, and communal areas were sometimes left unsupervised.
“Deployment of staff was disorganised and frequently chaotic.” from the report
Poor food and choice
seriousFood choices were restricted and were not always nutritious. Modified diets and religious or cultural food preferences were not consistently met.
“The food and drink offer across the home was generally poor.” from the report
Dignity not protected
seriousInspectors saw people without suitable footwear and one person left in soiled clothing after lunch. Staff did not always respond to basic personal care needs.
“The provider had failed to ensure people using the service were treated with respect and dignity at all times.” from the report
Failed leadership and checks
seriousGovernance and quality checks were not effective. Inspectors found a systemic failure of leadership and a culture of mistrust that contributed to poor care.
“There had been a systemic failure of leadership and management across all areas.” from the report
- 01How are you now checking that every medicine is available, recorded and given at the prescribed time?
- 02What changes have been made to staffing levels, staff deployment and nursing skills, particularly on the units supporting people with advanced dementia?
- 03How are falls, unexplained injuries and other incidents now assessed, recorded and referred to safeguarding when necessary?
- 04How do you make sure modified diets and religious or cultural food preferences are followed every day?
- 05What independent checks are now in place to show that care plans, complaints and quality improvements are being properly monitored?
This was an unannounced inspection of the overall care home, including both the premises and care provided, and all five key questions were rated. This explanation was written from the published report of 21 October 2023 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, September 2022
Rated Requires Improvement; inspectors found important progress, but medicines records, activities and leadership culture still needed strengthening, and the home was no longer in Special Measures.
This was an unannounced focused inspection on 26 and 27 July 2022. Inspectors spoke with people living in the home, relatives, staff and managers. They reviewed care plans, medicine records, staff files and quality checks.
The home had improved since its previous Inadequate rating. Inspectors found enough staff, better risk assessments, safer medicine systems overall, more personalised care plans and improved quality monitoring. Staff were described as kind, respectful and familiar with people's needs.
There were still areas needing improvement. Some medicine records did not contain all the information needed, some people and staff felt more activities were needed, and staff morale and confidence in leadership were still developing.
The overall rating was Requires Improvement. Safe, Responsive and Well-led were also rated Requires Improvement. Effective and Caring were not assessed in this focused inspection. The home had been in Special Measures, but it was removed from them after this inspection because it was no longer rated Inadequate and was no longer in breach of regulations.
Staffing improved
Inspectors found enough staff to meet people's assessed needs. The home had permanent unit managers and was using familiar agency nurses where needed.
“There were enough staff on duty to meet people's assessed needs.” from the report
Personalised care
Care plans had become more person-centred and were reviewed when people's needs changed. Staff showed that they knew people's preferences.
“People's care and support was now personalised and tailored to their individual needs.” from the report
Safety systems
Risk assessments, fire safety arrangements, safeguarding processes and infection control measures were in place. People and relatives told inspectors they felt safe.
“People had up to date risk assessments in place which included any factors that might affect the person, with actions for staff to take.” from the report
Better quality monitoring
The provider had introduced a live quality system covering areas such as care plans, medicines, infection control and health and safety. Inspectors found significant progress since the last inspection.
“The providers' quality assurance system was now more effectively utilised and monitored.” from the report
Activities still developing
needs fixingExtra activity staff had been recruited, but they were due to start after the inspection. Some people, relatives and staff still felt there were not enough activities.
“However, some staff, people and their relatives still felt more activities were needed.” from the report
Staff morale and leadership
needs fixingMorale had generally improved, but inspectors said this was still a work in progress. Not all staff were positive about the changes or confident in the management arrangements.
“We found the process of improving staff morale was a 'work in progress' and more effort and time was needed in this area.” from the report
Improvements need to last
needs fixingThe rating improved from Inadequate, but inspectors said they needed more evidence that the changes would become embedded and sustained.
“We would need evidence these improvements would become embedded and sustained before we were assured that consistently safe care was provided.” from the report
- 01How are you now checking that records for patch applications show the full history and that application sites are rotated safely?
- 02What information is available for every medicine given covertly or through a feeding tube, and how is staff competency checked?
- 03How many activity staff are now in post, and what regular activities are available on each of the four units?
- 04What actions are being taken to improve staff morale and make sure staff feel confident in the management arrangements?
- 05Which current ratings or recent evidence can you show us for the Effective and Caring areas that were not assessed in this inspection?
This was a focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not assessed in this visit, and the report says ratings for uninspected areas were carried over from the previous inspection. This explanation was written from the published report of 3 September 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.
Every inspection of Burrswood Care Home
7 rated inspections over 5 years: the service has slipped, from Requires improvement to Inadequate.
- October 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- September 2022Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2021Inadequatedown from Requires improvementSafe: InadequateResponsive: InadequateWell-led: Inadequate
- January 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvement
- March 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017
Registered with the Care Quality Commission on 30 November 2017.
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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