About the service: Burlington Care and Support Services is a residential care home that provides personal care and support for up to 13 people with a learning disability. Accommodation is provided over two floors within two separate but adjoining buildings. At the time of the inspection there were 12 people living at the home.

People’s experience of using this service:

We found the service was not operating in accordance with the regulation and best practice guidance. This meant people were at risk of not receiving the care and support that promoted their wellbeing and protected them from harm.

The provider did not have sufficient oversight of the service to ensure people received the care and support they needed that promoted their wellbeing and protected them from harm. Systems and processes to monitor the service were not effective and did not drive improvement. These included concerns with records, risk management, medicines, a lack of person centred care, infection control and the environment.

Staff told us people were encouraged and supported to use a range of healthcare services. We found the service were slow to seek advice or make referrals when people’s needs had changed.

Whilst we did not find people were being disadvantaged, people were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible. Related assessment and decisions had not been properly undertaken. Where some people were subject to continuous supervision the provider had not applied for this to be authorised.

Staff felt supported and valued and received regular training. However, there was a lack of monitoring of this training to check if it was effective.

People told us they felt safe and well cared for. Staff afforded people respect and provided care and support with compassion. Relatives did not raise any concerns about people’s safety and told us people were well cared for and looked after.

People and their relatives had confidence in the service and told us the home was well managed. One family member said, “I have no concerns about how the home is managed.” Another said, “My experience has been a positive one, I have always found the manager and staff to be incredibly helpful.”

Rating at last inspection: The service was previously rated as ‘Required Improvement.’ The report was published on the 16 February 2018.

Why we inspected: This was a planned inspection that was scheduled to take place in line with Care Quality Commission scheduling guidelines for adult social care services

Enforcement: We found repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have also made recommendations in relation to staffing levels, training and infection control. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up: This is the third consecutive time this service has been rated ‘Requires Improvement.’ We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least ‘Good.’ In addition, we will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Burlington Care and Support Services, known as Burlington House, is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation and personal care for up to 13 people with a learning disability. Accommodation is provided over two floors in two separate but adjoining units. At the time of our inspection there were 12 people living at the home: three people in one building and nine people in the other. The home does not provide nursing care. Where needed this is provided by the community nursing team.

The registered provider is also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run. The provider was supported in the management of the home by a service manager, who was in day to day control.

The home has been established for many years and was working in line with the values that underpin the Registering the Right Support. These values include choice, promotion of independence and inclusion, although the home did not always record how this was being done. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

Burlington House was previously inspected in December 2016 and was rated Requires Improvement. At that time we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have effective systems to manage risks to the people’s safety and welfare and had not notified the Care Quality Commission (CQC) of important events within the home. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to meet the requirements of the regulations. The provider confirmed that personal emergency evacuation plans and risk assessments for each person would be reviewed and rewritten as necessary and that CQC would be notified of all important events in the home that affect people’s safety and well-being. Since the last inspection, the home has kept CQC informed of events in the home. However, at this inspection in January 2018, we found improvements were still required to ensure people received safe care, with record keeping, people’s dignity was not always respected and systems were not effective in monitoring the quality and safety of the service.

Staff were able to describe people’s needs and knew how to keep people safe. However, this level of detail was not recorded in people’s risk assessments or support plans. Records relating to the management of risks to people’s health, safety and well-being were either insufficiently detailed or staff actions were not being fully documented. For example, one person’s risk assessment failed to guide staff about how to support the person at times of anxiety when they were at risk of self-harm. For another person, the actions taken by staff to ensure the person was safe when out of the home were not well documented. We found that not everyone’s dignity as being respected. One person had particular night time support needs and we found their room had an unpleasant odour. Although the provider told us the room was regularly cleaned, the odour remained. In addition, staff had placed plastic ‘clinical waste’ bags on one area of the person’s floor.

The provider did not have effective systems in place to assess, monitor and improve the service. Although they attended the home at least once a week, they did not have a system of documented audits or reviews to demonstrate their oversight of the home. T

Burlington House is registered to provide accommodation and personal care for up to 13 people with a learning disability. At the time of our inspection there were 11 people living at the home. Burlington House does not provide nursing care. Where needed this is provided by the community nursing team.

This inspection took place on the 9 and 13 December 2016; the first day of our inspection was unannounced. One adult social care inspector carried out this inspection. Burlington House was previously inspected in May 2014, when we found the provider did not have effective systems to identify, assess and manage risks to the health, safety and welfare of people or to regularly assess and monitor the quality of service provided. At this inspection, we found that although some improvements had been made further improvements were needed.

The registered provider is also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

Following our last inspection, the provider had introduced a new quality auditing system. We found this had introduced some improvements but was not fully effective to assess and monitor the quality and safety of the services provided at the home. Although some systems were working well. risks to people's health and wellbeing had not always been identified, assessed or mitigated. People’s individual needs were not always assessed or planned for. Whilst support plans and risk assessments reviews were taking place monthly, these had not identified the lack of information or instruction for staff in how to meet people’s needs. Where people had specific needs relating to their behaviour or lifestyle choices, risk assessments did not identify the risk of potential harm to other people living at the home, the person, or contain guidance for staff on how to manage these risks.

We looked at the personal emergency evacuation plans (PEEP) which were in place for people who lived at the home. The purpose of a PEEP is to ensure staff know how to assist each person to leave the building safely in the event of an emergency. We found these had not been completed for all people currently living at the home. This meant staff did not have all the key information they needed to assist people from the building in the case of an emergency.

We have made a recommendation that the provider keep the system for identifying risk and mitigating risk under review.

The registered manager had not always notified the Care Quality Commission of significant events, which had occurred in line with their legal responsibilities; this included the notification of safeguarding concerns.

People said they felt safe and well cared for at Burlington House; their comments included “I do feel safe,” “I’m very happy,” “It’s my home, and I like it here.” Relatives told us they did not have any concerns about people’s safety.

People were protected from the risk of abuse. The registered manager had developed an easy read document, which told people how they could seek advice or raise a concern. Staff had received training in safeguarding vulnerable adults and demonstrated a good understanding of how to keep people safe. Recruitment procedures were robust and records demonstrated the home had carried out checks to help ensure staff employed were suitable to work with people who are vulnerable due to their circumstances. Everyone we spoke with felt the staff were well trained and able to meet their needs.

Staff showed a good understanding of the Mental Capacity Act 2005 (MCA) and their role in maintaining people’s rights to make their own decisions. During the inspection, we observed staff putting their training into practice by offering people choices and

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

The people living at Burlington House valued the feeling of safety that the service gave them. People we spoke with told us that they felt safe at the home. They explained that the staff from the home would go out with them if they felt unsafe being in the community on their own. Others told us that the home had systems in place to keep a check on their safety if they were out alone. Staff and management were aware of proper safeguarding systems and knew what to do in the event of a safeguarding matter.

We were concerned to see a person apparently struggling with their mobility. However, the managers were able to explain what systems they had introduced to maintain the person's safety. The provider might find it helpful to note that no consideration of a professional assessment had been made.

The management and staff of the home were aware of their responsibilities under the deprivation of liberty safeguards (DoLS). They told us that at the time of our visit no one was subject to these safeguards. This was confirmed by some of the people who lived there, who told us that it was their informed choice to only go out with staff. For example, one person said "I would like to go out on my own, but I would have to learn how to."

Is the service effective?

Every person we spoke with told us that they liked living at the home. One person told us that it was "Lovely. Everything's good here." Another said "I like it here, this is my new home. I like Burlington House. I like it. I like the staff. I am happy here." It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. One member of staff told us "We give the guys what they want, rather than what we want. It’s their home. They are a very different set of people, each with their own issues." Staff had received training to meet the needs of the people living at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that the staff were patient and gave encouragement. For example, one member of staff asked "have you tidied your room?" as a reminder of what the person was supposed to be doing. Another person told us that staff helped them to wash their hair and back.

We saw a card sent by a relative which commented on how much better their relative was since being at the home.

We met a visiting professional who had referred one person to the home and was in the process of making a second referral. They told us that the staff “seem very friendly" and that their client "seemed relaxed."

Is the service responsive?

We heard how managers had attended meetings prior to a person moving into the home. This meant that they knew what to expect when the person arrived. We also saw, from entries on a log sheet, that a member of staff had attended best interests meetings for one person. This meant that the home was able to participate in making an important decision on the person's behalf.

Is the service well-led?

The home was managed by the Registered Manager, who was also the owner of the home. She was assisted by a full time service manager. We heard the staff and people living at the home speak highly of the managers. However, the Registered Manager told us that due to personal reasons they had not been in the home as much as they would like over the past year. The Registered Manager recognised that this meant that the paperwork was not up to standard. They believed that the hands-on care of people living at the home had not suffered and they invited us to observe the way people were cared for. The Registered Manager knew what needed to be done in order to be able to demonstrate compliance and they informed us of their intention to ensure that the paper-work will become compliant.

The home was in need of refurbishment and the Registered Manager told us that they intended to carry out a plan of works over the next year.

When we last inspected Burlington House in August 2012 we had some concerns over the record keeping, care plans and medication management systems. The home sent us an plan telling us what they intended to do to put things right. On this visit we looked at the action they had taken. We found that the home had implemented the changes needed, but some areas of record keeping, policies and procedures still needed to be improved.

We found that people were being offered choices and these were respected. Where people lacked capacity to make decisions people's rights were respected and decisions made in their best interests were being made in accordance with legislation.

We saw that each person now had a person centred plan for their care, drawn up with them and written in ways they were able to understand. One person told us about how staff had helped them write their care plan. They said “We sat and wrote it all down. I like (Staff member’s name) because she is my friend. She helped me do it”. Another person's plan had been filmed and was on DVD at their request.

We found that people's medication was being given out safely and stored correctly. The records regarding the administration of medication showed a full audit trail of medication received into the home and it's administration or disposal.

Staff were employed following a full recruitment process. People told us the staff supported them well. One said “Staff take me out. They are kind to me.”

We visited Burlington House on three occasions to complete this inspection. On our first visit to the home we spent time talking with the people who lived at the home. We also observed some of the care being delivered. On the third visit we spent time with the provider looking at the operation of the service. Our second visit had been terminated as there was no senior person available to speak with us.

We saw that all but two of the people living at Burlington House were able to express their views on the service verbally. Two people needed additional support from staff as they could not communicate their wishes verbally, but we were told and saw they were able to make their wishes known to staff in other ways. We saw that staff understood their communication.

We were told there was a monthly meeting at the home where people were encouraged to make comments on the service and suggestions as to changes they would like to be made. This meeting was chaired by a person chosen by the group, and comments fed back to the home's management for action.

We saw people being involved in making decisions about how they spent their time. One person told us they had been down into Torquay to buy some chocolate that morning and other people had gone out independently. As an example, one person had caught a bus to Totnes to meet up with some friends. We saw people being offered support and encouragement in ways that did not limit their independence.

One person told us they very much liked living at Burlington house, although they had not liked it when they first came. They told us the staff were very kind and were helping them to move forward into supported living.

Other people told us "I like my room. I like peace and quiet. They (staff) don't come up here very often, and I can do what I like". And other person said "I have hoovered and washed my hair today. Then I went out to Tesco's and ate some chocolate. I will do some laundry later".

One person we spoke with told us they had been out the previous day with staff to buy food for their birthday party to be held the following day.

We saw a person who lived at the home helping staff to prepare the lunch and hot drinks for everyone. We were told that people living at the home were involved in making decisions about the menus.

People we spoke with told us about the staff. One person told us "Some of them are nice, some not as nice. But I don't mind them all really". Another person told us that the staff "were very good, very nice" and another that they "Sort things out for me and help me to do things I want".