Burgess Care

The inspection was prompted in part by notification of an incident following which a person using the service had an unplanned admittance to hospital. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result,this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risks around bowel management. This inspection examined those risks.

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the provider had not ensured people’s experience met these standards.

The provider did not promote a positive learning culture and relatives did not always feel listened to when they raised concerns. Managers had not ensured staff followed the provider's systems and processes, resulting in missed opportunities to learn from incidents, safeguarding concerns and feedback. As a result, risks to people were not always recognised, monitored or acted upon in a timely way.

Facilities and equipment did not always meet people’s needs and parts of the home were not clean, well maintained or safe. Environmental risks had not always been identified or mitigated, which increased the risk of avoidable harm and compromised people's safety and wellbeing.

There were enough staff to support people, but they did not always have the range of skills required to care for people safely or effectively. Staff required more support and guidance to ensure they fully understood their role and leaders needed to undertake further staff development to contribute a positive culture in the service.

The service is a campus setting. People were supported in a mix of shared houses and single accommodation within Burgess Care. The provider had not consistently ensured people were involved in the local communities beyond the location. The model of care was such that people lacked opportunities to learn new skills and become more independent.

The provider and managers had not always made sure staff received training and regular appraisals to maintain high-quality care. The provider and managers were not always visible in the service. The provider’s checks had not promptly identified and consistently addressed shortfalls we found at this inspection, including in relation to consistency of recording, support for staff and the culture and governance at the location.

The concerns identified at this assessment demonstrated widespread failures in leadership, oversight and governance. Provider systems had not been effective in identifying and addressing environmental risks, poor practice and inconsistencies in how risks to people were monitored and managed. As a result, people were exposed to avoidable risks and did not consistently receive care and support which reflected the principles of Right Support, Right Care, Right Culture.

The provider was in breach of legal regulations relating to premises and equipment and governance. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.