About the service: Burlington Nursing Home accommodates a maximum of 40 people in one adapted building. At the time of this inspection 30 people were living at the home. Most people who lived at the service were living with dementia. 21 people received a service to support more complex nursing level needs, while nine people received a personal care service to support those with lower residential care needs.

People’s experience of using this service:

New staff had not been always been recruited safely and people could not be assured that new staff were of good character. This placed people at risk. We raised this with the registered manager who took action to address this during the inspection process. New staff were taken off the rota and replaced by agency staff while more thorough recruitment checks were completed.

Medicines were given safely to people. However, we found that staff did not always follow the advice and recommendations of an external healthcare professional which meant that one person did not always receive 'As required' medicines for pain relief when this may be needed.

Risks were not always clearly assessed for people. The action staff may need to take to safeguard people from harm or to provide person centred care was not always detailed in records. Nutritional risks were not always assessed accurately which may place people at risk of harm from malnutrition.

Electronic care plan records for people did not contain detailed, personalised information or medication assessments. There was a risk that new staff or agency staff would not know how to meet people's needs safely or in accordance with their personal wishes and preferences. By the end of the inspection process the clinical lead had begun to improve the basic information held in people's electronic records.

Since the previous inspection in July 2018, the provider had taken action to improve aspects of the service provided for people. We issued two warning notices at the previous inspection, the conditions of which had now been met. Lifting equipment was safely maintained and water quality was monitored safely. Despite this, aspects of the governance and leadership of the service were not effective in identifying some significant service shortfalls such as gaps in the recruitment processes for new staff.

An independent consultant had been commissioned by the provider to support them to make positive changes to the service. An electronic care planning system had been purchased and was being implemented at the time of this inspection. However, at the time of this inspection these improvements had not been fully embedded in daily practice and further breaches of Regulations were found. This meant that the provider did not always meet the legal requirements of their registration with the Care Quality Commission [CQC].

Despite some of the ongoing concerns identified, we observed that people were treated kindly by care staff throughout the inspection process. At the time of this inspection, people's relatives that we spoke to were positive about the experiences their relatives had at the service. Health and social care professionals told us that the provider and registered manager had been working positively with them to improve the service since the last inspection. Training and weekly support had been provided by West Sussex County Council to staff and the registered manager to help them to improve the service people received.

Rating at last inspection: Inadequate (25 October 2018).

The overall rating for this service is ‘Requires improvement’. However, the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken imm

This was an unannounced inspection that took place on the 11 July 2018. We also returned to complete a second day of inspection on the 13 July 2018 which was announced.

We previously inspected the service on the 29 June and 3 July 2017 at which time the service was rated as ‘Requires improvement’. There was a breach of Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was also inspected on the 4 and 5 October 2016 at which time the ‘Safe’ key question was rated as ‘Inadequate’ with an overall service rating of ‘Requires improvement.’

Following the last inspection in 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions rating to at least ‘Good.’ At this inspection we found that inadequate progress had been made and the previous breach of Regulation was repeated. We also found further breaches of Regulation at this inspection. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Following this inspection, we received an action plan from the registered manager. This demonstrated that they had begun to address the shortfalls identified at the service. We will review this at the next inspection.

Burlington Nursing Home 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.

Burlington Nursing Home accommodates a maximum of 40 people in one adapted building. At the time of this inspection 32 people were living at the home, one of who was in hospital. Most people who lived at the service were living with dementia. 23 people received a service to support a nursing level of need, while nine people received a service to support a residential assessed level of need.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 service is run.

We found significant concerns regarding the safety of the service provided to people. Maintenance checks for lifti

This was an unannounced inspection which took place on 29 June 2017. We also returned on the 3 July 2017. The registered manager was given notice of the second date as we needed to spend specific time with her to discuss aspects of the inspection and to gather further information.

Burlington Nursing Home is registered to provide nursing and residential care for up to 40 older people who may be living with dementia. At the time of our inspection 29 people were living at the home. People’s needs varied. Seven people were being cared for in bed. The majority of people residing at the home lived with dementia. 18 people required nursing care.

During our inspection the registered manager was present. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 service is run.

At our previous inspection in October 2016 five breaches of regulation were identified. These related to staffing, personalised care, safeguarding, safe care and treatment and good governance. In response, the registered manager sent us an action plan that detailed the steps that would be taken to achieve compliance. The service was rated ‘Requires Improvement’ in the effective, caring, responsive and well led domains and ‘Inadequate’ in the safe domain. An overall rating of ‘Requires Improvement’ was awarded.

At this inspection we found that improvements had been made in all areas apart from record keeping. People still did not have accurate or up to date records for all their identified needs, records for monitoring fluids and positioning were not completed in full and some people’s records contained conflicting information. You can see what action we told the provider to take at the back of the full version of the report.

People said that the registered manager was approachable and that improvements in the management of the home had taken place. Since our last inspection the quality assurance processes in the home had been reviewed and an increase in service audits had taken place. We found that where improvements had been made these needed to be fully embedded to help ensure people received a consistent service. Improvements had taken place to manage risks to people’s safety but further work was needed. People’s records did not always evidence that known risks to their wellbeing were being monitored appropriately. On the second day of inspection, as a result of the feedback we gave on the first day, the registered manager had reviewed the system for monitoring people’s positioning and fluid intake. This included changing the recording format, staff handovers and the frequency of audits. This gave us assurances that potential risks to people would be managed more safely.

Since our last inspection staffing levels had been reviewed and a dependency assessment used to decide safe staffing levels. During the inspection we observed a staff presence on both floors of the home at all times. However, there were two occasions when there were no staff present in the lounge and as a result people were left without the required assistance.

At our last inspection we received mixed feedback from people about the caring service provided to people. At this inspection the majority of people said that the service was caring. Despite people commenting positively we found that staff did not always practice a caring approach. We were given assurances by the registered manager that action would be taken in response to our findings.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. Policies and systems were in place to support this practice. We did note that some people’s mental capacity assessments were not always decision specific or ac

The inspection took place on 04 and 05 October 2016 and was an unannounced inspection.

Burlington Nursing Home is registered to provide accommodation and care for up to 40 older people who live with dementia. It is situated in a residential area of Bognor Regis, West Sussex. At the time of this inspection, there were 34 people living at the service. The home is purpose built and accommodation is provided over two floors in single occupancy rooms. A passenger lift provides access between the floors. There is a separate seating area and communal open plan lounge with dining area.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 service is run.

We found that people were at risk of harm because risks had not always been minimised effectively through appropriate support and regular monitoring. We identified staff had used improper physical interventions for two persons, one of which had recently moved from Burlington Nursing Home. As a result of our inspection, the registered manager, identified they were unable to meet the needs of two people, which resulted in those people being served notice to leave Burlington Nursing Home. Following our inspection, the registered manager was working with the local authority to find a new home that could meet the person’s needs.

Staff knew what actions to take should they suspect abuse and received appropriate training in keeping people safe. However, staff and the registered manager lacked insight into what might constitute abuse and neglect by omission of care. Resulting in the registered manager failing to notify the local authority safeguarding team and the Commission of incidents that could constitute possible neglect and other forms abuse. In response to our findings, the registered manager reported all the safeguarding concerns to the local authority safeguarding team, identified at the time of inspection.

Whilst staff were safely recruited, there were not enough staff to meet people’s needs. The registered manager agreed with our findings at the time of inspection and following our inspection, had reassessed the needs of people’s needs, resulting in the staffing levels being increased by an additional two hours per person, per week for people who received care in bed. . The registered manager told us the additional increase would mean people who spent most of their time in bed would be better supported emotionally and physically. This also meant the service was enabled to be more flexible to meet people’s needs.

Staff had completed training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). Applications had been made to the local authority for DoLS and some assessments had been carried out of people’s mental capacity. However, we found staff lacked understanding about the Mental Capacity Act 2005, Deprivation of Liberty Safeguards, and obtaining consent and carrying out care and support in people's best interests. There were restrictions and interventions being used, imposed on people that did not consider their ability to make individual decisions for themselves, as required under the MCA Code of Practice. At the time of our inspection, the registered manager agreed with our findings and had started the process of reassessing people’s needs.

Some staff practices showed a lack of respect for people and did not promote their privacy and dignity. We had to intervene on several occasions to ensure people received safe and appropriate care.

For people who were less mobile or who remained in bed, there were few opportunities to engage in activities and people were seen sitting in the lounge or their bedroom with no meaningful activity or positive

Burlington Nursing Home provides residential and nursing care for up to 40 elderly people who may also have dementia.

The inspection team consisted of one adult social care inspector. On the day of our inspection there were 34 people living in the home, 26 of whom the manager informed us had dementia. We spoke with 15 people who lived in the home and with 10 relatives. As some people were unable to tell us about their care and support we observed staff practice and their interactions with people and listened to the views of relatives.

We observed how staff supported people and looked at documents including five care plans, training records and management reports.

We considered our inspection findings to answer questions we always ask:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with dignity and respect by the staff. People told us they felt safe and comments included, “It is such a nice place to be, everyone is so kind to you and you can have all your own things around you". A family member said, “I feel my relative is safe and happy here and that is a great weight off our minds”.

There were systems in place to support the provider to learn from events such as incidents and accidents and these were reported to the statutory bodies when required. The home provided staff with guidance in relation to the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) to ensure people’s freedom and rights were respected. No current applications had needed to be submitted. Where people required assistance in making some decisions about their lives we saw that meetings had been held with families and other professionals to ensure people’s best interests were upheld.

Is the service caring?

We observed how members of staff cared for and treated people. We saw this was done in a patient, caring and friendly manner. People told us they were treated with kindness and respect. Comments included, “The girls (staff) are very friendly and very relaxed and they just let you ‘be’. I am never afraid and just happy to be living here”.

Is the service effective?

People’s health and emotional needs were assessed and kept under regular review. Wherever possible people were involved in the compilation of their care plans. Families told us they were given opportunities to be involved in all aspects of their relative's care. Care plans detailed people’s nutrition and hydrations needs and these were regularly reviewed and updated. The manager had an effective system to regularly assess and monitor the quality of care and support that people received.

People told us they had access to good healthcare support. Comments included, “If I am feeling unwell the staff will always call the doctor for me and the nurses here are very good and very attentive.”

Is the service responsive?

We observed that staff responded promptly to people’s requests. Call bells were answered straight away and requests for assistance were treated promptly and with kindness and patience. During our visit we saw that staff had concerns over the changed behaviour of one person. A doctor was called and attended the person later in the day. We saw that monthly audits were carried out to identify changes in people’s needs and referrals made to health professionals as appropriate.

People’s spiritual and emotional needs were recorded and addressed and there was a programme of activities and outings on offer. On the day of our visit there was a garden party in the afternoon. We saw that people greatly enjoyed this event and having their families to visit.

Is the service well led?

There were systems in place to audit the quality of service provided and to monitor the safety of the environment.

Staff told us they felt well supported by the manager and provider. They were aware of the need to protect people and ensure they received a good quality service at all times. A family member that spoke with us said, “My relative has lived here for six years. I can’t fault the care. The staff are always kind and friendly and the food is good. If I have any concerns at all I talk to the manager and it is very soon sorted out”

This visit was undertaken as part of a themed inspection programme looking at the quality of dementia care. At the time of this inspection there were 33 people living at the home, 27 of whom the manager informed us had dementia. We gathered information from a variety of sources. These included talking with eight people who lived at the home and two relatives. We also spoke with the manager and four members of staff. As some people were unable to tell us about their care and support we completed a 30 minute observation using a tool called SOFI. This stands for Short Observational Framework Inspection. This is a tool especially designed to help us understand the quality of care that people receive. We also left comment cards for people to complete if they wished to inform us of their views on the home. Two people returned completed comment cards.

Everyone told us that they were happy with the care and support they received. For example a relative said, "The staff are very good, and well trained dealing with people with dementia. When problems arise with behaviour of some residents, the staff deal with it in a kind, quiet and professional manner".

People told us that they were happy with the support they received from the home to access healthcare professionals. One person told us, "They make sure I am happy and healthy. They seem to spot things before I do! They arranged for me to see the doctor and chiropodist". Another person said, "There seems excellent contact with the local GP's".

The provider had an effective system to regularly assess and monitor the quality of dementia care that people received. This included involving and informing people. One person told us, "There is a residents and carers group and niggles or suggestions can be freely aired. It's a lovely home where you really feel listened to".

During our visit we spoke with four people who were using the service, three members of staff and saw correspondence from peoples relatives. People who used the service told us that they liked living at the home and that the service met their needs. People told us that staff were nice and very considerate and that there was always someone around to provide help and support. Comments included the following: "we are very settled here." and, "They are wonderful."

We made observations throughout the visit and saw people being offered choices as to what they wanted to eat or what activities they wanted to take part in during the day. We saw people being addressed in a respectful manner. We looked at peoples individual care plans and saw that the information recorded enabled staff to plan and deliver the required level of care and support on an individual basis.

We saw that regular audits of the service were completed by the provider ensuring that people who used the service benefit from a service that monitored the quality of care that people received. We saw that the home had recently been decorated and one person that used the service told us that he helped choose the wallpaper

Staff told us that they had regular training and that they felt that they were supported to carry out their roles and meet the needs of people who used the service.

People said that they had no complaints about the service and that if they did they would speak to the staff or the manager

Some of the people that lived at Burlington Nursing Home had impaired memory and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people had we spent time observing what was going on in the home, how people spent their time, the support they received from staff and whether they had positive outcomes.

We spent an over an hour watching people in the lounges and dining room and found that overall people had positive experiences. In the main, staff assisting them knew what support they needed and they respected their wishes if they wanted to manage on their own.

All people who we were able to have a conversation with, said they were happy with the staff and the care they received. Seven people expressed the view that the home was not adequately heated.

A few people told us that they are very happy with the care they receive at Burlington Nursing Home but others raised some concerns about how they are treated. The majority of the people living at the home are unable to talk to us about the care they receive because they lacked mental capacity.