Burntwood Lodge

We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We identified breaches of legal regulation relating to person centred care, risks related to people’s care, staff training and supervision and governance.

Governance and oversight systems were ineffective and had failed to identify or address issues relating to medicines management, risk monitoring, safeguarding, staff training, communication support, infection prevention and control, mental capacity and person-centred care.

Assessment and transition processes were not robust. A person with a specific health condition had been admitted to the service without a sufficiently detailed assessment of suitability. People's health needs were not always effectively monitored. Oversight of fluid intake, continence care, stoma care and constipation risk was inconsistent. Whilst incidents were recorded and immediate action was usually taken, there was little evidence of analysis, learning or improvement. Safeguarding concerns were not always supported by documented investigations and records to monitor emotional distress were not analysed to identify trends or preventative strategies.

Activities were limited and largely focused on attendance at day centres, with few opportunities for meaningful individual pursuits or evening activities. People were not always supported to exercise choice and control; communication methods were not adapted to meet individual needs and engagement processes such as resident meetings and key worker sessions were not always meaningful.

Staff demonstrated caring qualities, but practice was not always consistent. Training in Right Support, Right Care, Right Culture had not been provided and leaders lacked the required specialist learning disability and autism training. Opportunities for learning, improvement and quality assurance were not effectively embedded within the service.

People were supported by a staff team that generally knew them well and there were positive examples of kind and caring interactions. People appeared comfortable with staff, were well presented, lived in personalised bedrooms and were supported to access healthcare services, including hospital appointments. There were sufficient staff to meet people's needs, recruitment processes were robust, and environmental and fire safety checks were completed.