Burgundy Care Services Ltd improved from Requires Improvement to Good across all inspected key questions (Safe, Effective, Well-led), having resolved a previous Regulation 19 breach around recruitment practices. People and relatives spoke highly of the service, staff were well-supported, and governance systems were found to be effective.
Strengths
· Robust pre-employment checks including DBS now in place, resolving previous Regulation 19 breach
· Electronic medicines management system prevents staff logging out before administering required medicines
· Personalised electronic care plans and risk assessments accessible to families via mobile app
· Staff receive quarterly supervision, regular team meetings, and spot checks to ensure care standards
· Strong working relationships with local authority, GPs and community nursing service
Quality-Statement breakdown (14)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Assessing risk, safety monitoring and managementGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
Burgundy Care Services Ltd was rated Requires Improvement overall, with breaches of Regulations 12 and 17 relating to unsafe medicines management, inadequate risk assessments, task-focused care plans and a lack of robust audits and quality assurance. Staff were consistently praised as kind and caring, but governance had not kept pace with current best practice or evidence-based guidance.
Concerns (18)
criticalMedication management: “staff were not keeping a record of the medicine support given to a person for each individual medicine on every occasion”
criticalCare planning: “Care plans were not recorded in a person-centred way to enable an understanding of the person's personal history, individual preferences, interests and aspirations.”
criticalGovernance: “Systems and processes and were not robust enough to monitor and improve the quality of the service.”
criticalGovernance: “the registered manager had not undertaken individual formal audits such as care plan audits, daily record audits, staff management of medication, spot check audits”
moderateMedication management: “Cream charts were not in use to identify where these should be applied and where they had been applied. There were no patient information leaflets in the care files”
moderateRecord keeping: “the registered provider did not keep a record of The Provision and use of Work Equipment Regulations 1998 (PUWER) and The Lifting Operations and Lifting Equipment Regulations 1998 (LOLER) checks”
moderateStaff training: “one staff member had not received any training or had their knowledge checked before commencing work on their own and other staff training was out of date.”
moderateSupervision / appraisal: “there was a lack of evidence at inspection to confirm the frequency and the quality of spot checks and supervision.”
moderateStaff competency: “17 % of people told us care staff did not have the necessary skills.”
moderateMissed or late visits: “People told us calls were regularly late but they understood why.”
moderateStaffing levels: “they had been through a difficult time this year, when they did not have enough staff due to the difficulty recruiting in the rural area.”
moderateOther: “One file we looked at showed that the person had started work before the two references had been obtained.”
moderateComplaints handling: “Complaints were not compiled to show how the service had analysed and responded to information gathered or used this information to make improvements”
moderatePerson-centred care: “care plans remained task focussed and not person centred following review and additional information learnt about people from working with them was not added”
moderateSafeguarding: “the safeguarding policy did not contain the telephone or address details of who to contact nor did they reference the local safeguarding policy.”
moderateLeadership: “both the manager and director had taken leave together and they told us no one else could access all the records we needed to conduct our inspection.”
minorCommunication with families: “25 % of people who returned their questionnaire told us the information received from the service was not clear and easy to understand.”
minorConsent / capacity: “staff were unaware of more formalised assessment of capacity and the process required in relation to best interest decision making.”
Strengths
· Staff were described as kind, caring, respectful and protected people's privacy and dignity
· 100% of people who returned questionnaires said they felt safe from abuse or harm from staff
· Staff had a good understanding of safeguarding and how to identify and report abuse
· Staff encouraged independence and supported people to take part in community activities and religious practices
· Use of technology including a log-in/log-out system enabled real-time monitoring of visits
Quality-Statement breakdown (5)
safe: Is the service safe?Requires improvement
effective: Is the service effective?Requires improvement
caring: Is the service caring?Good
responsive: Is the service responsive?Requires improvement
well-led: Is the service well-led?Requires improvement