The inspection took place on 26 November 2018 and was unannounced.

Burlingham House provides residential care for up to 49 older people, some of whom may be living with dementia. The home is a period building over two floors. A recently opened and purpose-built extension provided en-suite facilities and a number of communal areas and outside spaces. At the time of our inspection there were 34 people living within the home.

There was a registered manager in post at the time of this inspection. 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.

Our last comprehensive inspection was carried out in June 2017, and we found that systems to monitor the quality and safety of the care provided or to limit risks to people's safety were either not effective or were not in place. This resulted in some people experiencing poor care. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. We subsequently warned the provider about this and told them that they had to meet this regulation by 18 August 2017. We then carried out a focussed inspection in October 2017, where we found that the necessary improvements had been made and the provider was no longer in breach of this regulation. However, there were still improvements needed in the governance systems in the home.

At this inspection we found that further improvements had been made to the governance and there were effective systems in place to monitor and review the service. Audits were carried out in many areas to assess the quality of the service. Action plans for improving the service were ongoing, and actions were completed in a timely manner.

Further improvements were still needed to ensure that people received fully individualised care, through adding detail around end of life and health conditions in their care plans. Further oversight of the daily records of people’s care was also needed to ensure they received care as they wished.

Staff administered people’s medicines as they had been prescribed and there was oversight of medicines administration which meant any errors were promptly identified and acted upon. Risks to people were assessed and mitigated, and the environment was kept safe for people to live in. Staff had a good knowledge of safeguarding and how to report any concerns relating to abuse. There were enough staff to keep people safe, and they were recruited safely.

Where needed, people’s mental capacity was assessed and decisions made in people’s best interests. Where people were deprived of their liberty, this was compliant with relevant legislation.

Staff were competent and received training which was relevant to their role. New staff underwent comprehensive inductions and shadowed more experienced staff to learn the role.

People received a choice of meals and drinks, including any specialist diets such as diabetic and soft diets. Staff supported people with accessing healthcare when they needed, and followed any recommendations from healthcare professionals.

Staff and people built good relationships and staff were caring towards people, respecting their dignity and privacy. People’s needs were assessed prior to moving into the home, and these needs informed a care plan which guided staff on how to meet people’s needs. There were not always specific end of life care plans in place, and people did not always receive all personal care as expected. However, people reported that they were happy with the care they received.

There were activities available for people to join, as well as trips out sometimes. People were encouraged to join in with things, and one to one support was available if they chose not to.

People felt comfortab

We carried out an unannounced comprehensive inspection of this service in June 2017. A breach of the legal requirements was found and a warning notice was issued in respect of this breach. After the comprehensive inspection, we gave the provider until 18 August 2017 to meet the legal requirements in relation to this warning notice. We undertook this focused inspection to check that they had undertaken changes to meet these requirements. This report only covers the findings in relation to that notice.

We have not changed the overall rating for this service as a result of this inspection, which was only to follow up our enforcement action. The service remains requires improvement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link Burlingham House on our website at www.cqc.org.uk.

Burlingham House is a residential home providing care and accommodation for up to 49 older people. There were 29 people living in the home at the time of our inspection visit, some of whom were living with dementia.

At the time of this inspection, the home did not have 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 and associated Regulations about how the service is run. There was a new manager in post who had been working in the service for three weeks, and was planning to register with CQC.

At the previous comprehensive inspection effective monitoring systems were not in place to ensure quality and safe care was provided. This had resulted in some people receiving poor care and being at risk of harm.

At this inspection we saw that improvements had been made and that more effective systems had been developed since our last visit and were now in place. These were to monitor the quality of care and the safety of people living at the home, and to reduce the risk of harm and poor care. However, further improvements and actions were needed.

The Warning Notice we issued had been complied with.

The inspection took place on 6 and 7 June 2017 and was unannounced.

Burlingham House provides residential care for up to 49 older people, some of whom may be living with dementia. The home is a period building over two floors. A recently opened and purpose built extension provided ensuite facilities and a number of communal areas and outside spaces. At the time of our inspection there were 32 people living within the home.

There was no registered manager in post at the time of this inspection. However, an application had been received to register a manager and, at the time of this inspection, was being processed. This person had started in post in late February 2017, was available during the inspection and is referred to as the ‘manager’ throughout this report. 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 completed a comprehensive inspection of this service in October 2015 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Two breaches of legal requirements were found in regards to the need for consent and meeting nutritional needs. The provider sent us a plan to tell us about the actions they were going to take to meet the breaches of the regulations.

A further comprehensive inspection was carried out in November 2016 where we again found that the service was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Two breaches of legal regulations were found which related to the safe care and treatment of those that used the service and governance. We asked the provider to send us a plan that set out the actions they planned to take in order to meet the regulations. This was not received by CQC.

At this inspection in June 2017, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to safe care and treatment, staffing and governance. Whilst some improvements had been made, the service continued to be in breach of the regulation relating to governance for a second consecutive inspection. The service also continued to be in breach of the regulation involving safe care and treatment.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The new manager had implemented an action plan when they first started in post in order to address those issues we had identified at the inspection in November 2016. However, although we saw processes had been introduced to assess, monitor and improve the service, these had not been fully effective or firmly embedded. They did not demonstrate sustained improvement.

The risks to those that used the service had been identified but not fully assessed, reviewed or managed. Delays had occurred in recording measures to control these risks and keep people safe from the risk of harm. People had not received their medicines as the prescriber had intended.

Some people had to wait for assistance or had no way of alerting staff when they needed care or support. Staff were poorly deployed meaning areas of the home were left without staff cover for periods of time.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service had submitted some DoLS applications to the local authority. However, they could not demonstrate that they had adhered to the principles of the MCA prior to making these applications.

People had been included in the planning of their care and reviews of planned care were underway at the time o

Burlingham House is registered to provide accommodation and care for a maximum of 31 older people At the time of our inspection there were 30 people living in the home.

The home did not have a registered manager in post. The manager had not submitted their application to become the registered manager. For the purpose of this report they will be referred to as ‘the manager’ rather than 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.

At the last inspection on 7 and 8 of October 2015, we asked the provider to take actions to make improvements to the systems they had in place to ensure that people’s nutritional and hydration needs were being met and to act in accordance with the Mental Capacity Act 2005, and this action has been completed.

During our inspection we identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014

A breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014 was found regarding the management of risks to people’s health and welfare. People’s risk assessments and care plans were not updated to reflect people’s most current needs and action was not always taken to mitigate risks to people’s health and welfare. Risks associated with the environment of the service were also not monitored.

There was a lack of effective systems in place to monitor and assess the quality of service being delivered. Audits to monitor and assess health and safety and people’s care were not carried out and the provider did not complete any audits. These findings constituted a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014. The manager was candid about the improvements that were needed to take place and had developed systems which would be implemented to assess all aspects of the service.

You can see what action we told the provider to take at the back of the full version of the report.

We found that staff working at Burlingham House did not always act in accordance with the Mental Capacity Act 2005 (MCA) and MCA assessments were not detailed. There was little detail in people’s care plans to detail how people should be supported with making choices and what choices they could make for themselves. Staff did not have a good understanding of the MCA and how to apply it in their work with people.

The staff were not always caring and some staff did not speak to people in an appropriate way. On the other hand, other staff were caring and attentive to people’s needs and wishes and provided reassurance where needed.

Accidents and incidents were not consistently recorded and there was no system in place to monitor and analyse this information.

There was enough staff to support people and people’s dependency was assessed on a regular basis so staffing levels could be adjusted accordingly.

Staff were supported through regular training relevant to their role and could access additional training if they wished. Staff did not receive frequent supervision to help them develop in their role. Staff felt supported by the manager and their colleagues and attended regular staff meetings.

Staff had received training in safeguarding adults and were aware of the correct procedure to follow to report concerns. The manager was proactive in addressing any safeguarding concerns.

People’s relatives and friends were welcomed and in Burlingham House and there were few restrictions on the times people could have visitors.

There was clear leadership in the home and staff were aware of who was in charge of each shift and who they should report any concerns to.

Prior to our inspection the Care Quality Commission (CQC) had received concerns about the care provided at Burlingham House. In particular there were concerns about how the home managed people who suffer falls. There were also concerns raised about how the home manages it cleanliness and protects its residents from infections such as diarrhoea and vomiting.

The person named in the report as registered manager is no longer correct. The provider is in the process of formalising the acting manager's position as registered manager.

The purpose of this inspection was to check that people who used the service were provided with safe and effective care that met their needs. We spoke with the manager and staff members who told us about recent improvements made in the service to meet people’s needs and expectations.

We conducted this inspection to establish the following about Burlingham House:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive and

• Is the service well-led?

An adult social care inspector carried out this this inspection on 12 August 2014.

As part of this inspection we spoke with four people living at the home, two friends of people living in the home, the manager, three members of care staff, laundry staff and cleaning staff. We reviewed records relating to the management of the home which included four care plans. We also looked at staff training files.

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

People were able to indicate to us that they felt safe living at Burlingham House. We saw that the provider had satisfactory recruitment procedures in place. This ensured that only suitable people were employed to work with vulnerable adults.

The manager was able to tell us how they protected vulnerable adults. They told us how they responded to and reported safeguarding incidents to the relevant authorities. Staff we spoke with demonstrated knowledge of safeguarding adults and how to respond to and report safeguarding issues. We saw how staff kept people free from harm whilst observing them using hoists and wheelchairs. We saw how staff re-assured the person at all times.

There was a system of assessing risks designed to keep people living in the home, and staff, safe from harm. Risk assessments were appropriate to people’s current and changing needs.

There were recently implemented systems in place to reduce the risk and spread of infection. An audit to check cleanliness was being prepared at the time of the inspection to meet the Department of Health's code of practice on the prevention and control of infections.

The provider had an effective system of recording person centred information. This meant that staff relayed important information to other staff relevant to the person's care. People were provided with their medication when they needed it.

Staff were supported with training which enabled them to do their job effectively and safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to people living in care services. At the time of the inspection fourteen people required these safeguards. Applications had been made to the appropriate authorities however the provider had been told of a long delay in processing the submissions. Proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when DoLS should be implemented.

Staff understood their roles and responsibilities in making sure people were protected from the risk of abuse. The provider ensured that all staff were kept up to date with safeguarding training and accompanying reporting procedures. The premises were well maintained and met the needs of people living in the home.

We noted that the provider had emergency and contingency plans in place to secure and maintain the safety of people using the services and staff.

Is the service caring?

We observed that people received helpful, consistent and respectful support from care staff. One person told us, “It’s okay here, but I hope to be going home soon.” Care and support plans were up to date and reflected the support needs of people living at the home. People we spoke with understood their care plan and met regularly with their key worker to discuss daily living events and any concerns they may have. Visitors told us how impressed they were with the welcome they received each time they visited.

Is the service responsive?

People's care and social needs were assessed and reviewed on a monthly basis or as and when needed. Where changes to people's needs occurred, the service referred to other health and social care professionals for advice and guidance if required. All such changes were documented and recorded. We noted however that there were some lengthy delays in getting requested services through from the local GP practice. These delays were outside the control of the provider.

An activities programme was in place to ensure daily activities were made available for those wishing to take part. For example reminiscence, quizzes and bingo took place. At the time of the inspection chair exercises were taking place in one lounge and dominoes in another. No one was pressured to take part in activities if they did not want to. There were quiet lounges available for people who did not wish to take part in activities. There was also a large conservatory available to people living in the home.

Is the service effective?

People using the service that we spoke with said, or indicated to us, that the care and support provided was satisfactory. The majority of people we spoke with did accept that the care provided was in their best interests. From our observations we saw that care and support was effective and consistent. People were supported to be as independent as possible.

We saw that people’s care needs were assessed by staff prior to and on their admission to the home. We saw people's care needs were monitored through a review system. A recent review of care records had resulted in changes relating to how reviews were recorded. This helped the home to meet people's expectations and needs.

One person living in the home told us that the food was, ‘…much of a much-ness…’ Another said, “I eat everything I can.” When asked if they got enough to eat they replied, “Oh yes, always enough and if I ask for more I always get it or something else I might take a fancy to.”

Is the service well led?

The views of people using the service and, where possible, their families were sought. Staff told us that they felt supported and had received sufficient training to carry out their role effectively. Staff training records reflected this. Staff added that if they felt they needed further or additional training or support that they were confident this would be arranged by the provider. This told us that the provider took reasonable steps to keep the staff updated and trained to a high professional standard.

Quality monitoring systems were in place and a programme of audits was scheduled to ensure that people received a good service.

People’s personal care records, and other records kept in the home, were kept safe and filed appropriately and securely.

Staff were clear about their roles and responsibilities. They spoke of how they worked as a team with the needs of the person central to the work they did.

People told us that they liked living at Burlingham House. One person said, “It is very good here. The staff are good and kind”. Another person stated, “The food is good and there is a lot of variety. They will do you something else if you don’t like what’s on”.

Where possible, people gave their consent to care and treatment or alternatively their relative acted on their behalf. Care records detailed the support that each person needed and they were kept under regular review so that staff were made aware of any changes to the person’s needs.

Staff demonstrated good understanding about protecting people from abuse because they had received training about this. They were aware of how to report concerns and knew the location of contact details for the Norfolk safeguarding team.

The appropriate checks were made when recruiting staff to ensure that only appropriate people were employed. Staff files included most of the information we would expect to find about people employed by the service, although no full work history was available at this inspection.

Effective systems were in place to monitor the quality of the service. Risk assessments were completed regularly and kept under review to ensure that the environment was safe for people living and working at the service. There was an effective complaints procedure in place that was known to the people living at the home.

We spoke with nine out of the 30 people who were at the home when we visited. They told us they felt well cared for and supported by staff. One person said, "The staff are very kind and they respect me. If I make a decision they respect it." We saw people in various parts of the home including communal areas. Organised activities were taking place in the quiet lounge, with five or six people joining in. One person told us, "I like to knit. I'm knitting squares to make a blanket for a babies cot."

People said they were listened to and described how they had put suggestions in the suggestion box and the manager had acted on them. People also knew how to complain if they were dissatisfied with the service. When speaking about lunch, one person said, "The food is good most days but the portions are too big."

People using the service spoke highly about the staff. We were told, "Staff are very good but there's not enough of them." However, we were also told that staff were always available when needed and that they responded quickly when the call bell was rung.

We observed staff interacting with people and for the most part the interactions were positive for the person. Staff spoke kindly and offered people choices that were respected. Efforts were made to preserve people's privacy and dignity when assisting people in and out of chairs. Jokes and laughter were shared between staff and people using the service. We saw visitors being welcomed to the home.

People said that they thought the staff looked after them well. They were able to spend time in their rooms if they wanted to, or to use different lounges as they wished. One commented, "I would like to have a trip out some time."

One person recognised that they were fussy about their food and said that sometimes the quality varied. This was confirmed by a visitor.

Some people were not able to tell us clearly what they thought so we spoke to some visitors as well as people living in the home. We were told that some staff would 'go the extra mile' to support people and that staffing levels had improved recently. They had identified that there had been a lot of staff turnover so would welcome a period of consistency and stability.

We were told that members of the management team were approachable and would deal with issues.

Most people with whom we spoke were satisfied with the way they were supported by staff. We did have some conflicting views, particularly about food. However, the majority of people with whom we spoke expressed a high degree of satisfaction with the staff, the way they were supported and the quality and choice of food.

People told us they felt safe in the home.

The inspection took place on 7 and 8 October 2015 and was unannounced.

Burlingham House provides care and support for up to 31 people, some of whom may be living with dementia. At the time of our inspection there were 29 people living there.

There was a registered manager in post. 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 the time of our inspection the registered manager was spending three days a week at Burlingham House and two days a week at another location registered with the same provider.

At this inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the arrangements for managing people’s nutritional needs were not robust. In addition, people’s human rights were not always protected. These concerns had not been identified and addressed by the provider as quality monitoring checks were not effective.

You can see what action we told the provider to take at the back of the full version of the report.

People were supported by staff who had undergone robust recruitment checks to ensure they were suitable to work in care. There were consistently enough staff to safely meet people’s needs. Staff understood what was required in order to protect people from harm. Medication was managed and administered safely and in line with good practice.

Staff had received training in order to support people but the skills required were not consistently demonstrated. Although people benefitted from seeing a range of healthcare professionals, the service had not ensured that people’s nutritional needs were met or provided the support to ensure people’s skin remained healthy.

The Care Quality Commission is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty safeguards (DoLS) and report on what we find. People were not being deprived of their liberty unlawfully, however we found discrepancies in the assessments of people’s mental capacity and in the recording of their ability to make decisions.

People were supported in a happy environment by staff who demonstrated warmth, kindness and compassion. Staff knew the people they supported well and encouraged choice and individuality. People’s privacy and dignity was maintained and staff understood the importance of people being involved in decisions around their care and support. Activities were provided however they were not always based on people’s individual needs and interests.

Although care records gave staff enough information to support people, they lacked personalised detail. The service had recognised and assessed people’s needs but had not always provided care plans to assist staff to support people in those areas. However, people’s needs were reviewed regularly and people were involved in decisions.

The service had a supportive culture. Staff morale was good and staff felt supported and encouraged in their roles. People received continuity in their care and support because there were systems in place to adapt the staffing levels as required. The service sought people’s views and comments and people felt confident in raising concerns. However, there were some shortfalls in consulting people, which had an impact on the service’s ability to develop and improve the service.