Burnham

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. Fire safety risks had not been well managed, fire drills had not taken place and weekly fire alarm testing was intermittent. This was a breach of the regulation concerning safe care and treatment. Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff knew people well and were able to identify changes to health and identify care and support needs. We could not be assured that people benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. This was because there was no record of the analysis and actions. Medicines were administered safely. Medicines stock did not always balance with records. Staff were not always recruited safely, the human resources team took action to resolve this during the assessment. The provider’s systems to ensure appropriate numbers of suitably trained and skilled staff were deployed on shift was not robust. This evidenced that the legal requirement in relation to staffing had not been met. There was a plan in place to make sure staff had ongoing support in the form of supervision and appraisal meetings. The provider worked with people and partners, including local authority care managers and health professionals, to establish and maintain safe systems of care. The provider had systems and processes in place to detect and control potential risks in the care environment and processes in place to assess and manage the risk of infection.

People were involved in their assessments and care planning processes. Before people moved into the service their needs were assessed. Care plans were in place which detailed people’s care and support needs but these required reviewing and updating to include people’s changing needs. The provider had systems and processes in place to meet people’s nutrition and hydration needs. The service worked with GP’s and health professionals to meet people’s health needs. The provider had a clear process in place to escalate health concerns. Staff had a good understanding of meeting people’s changing needs.

People were treated with respect and kindness. People were supported to be as independent as they could be and were actively making day to day decisions in their lives. The provider had systems and processes in place to promote and support staff wellbeing. Staff told us they received appropriate support.

The management team told us that they and the service were looking at ways to continually improve, some actions to make improvements had taken place and more were planned. Accident, incidents, complaints or other significant events were recorded. However, there was no evidence to analyse the trends and patterns. Systems and processes to audit and check the service were in place, however these were not always robust. This evidenced that the legal requirement in relation to good governance had not been met. Staff told us they liked working in the service. Staff said the new management team were supportive and approachable. Staff were confident that they could discuss any concerns with the management team and these would be acted on.