About the service: Burrswood Care Home consists of four houses. Crompton House residential unit, Dunster House, nursing unit, Kay House residential unit for people living with dementia and Peel House nursing unit. It is registered to accommodate up to 125 people.

Therefore at the time of this inspection 106 people were living at the home.

Since our last inspection the home had changed ownership from Bupa Care Homes to Advinia Care Homes Limited. Because of the change in ownership this inspection is classed as the first inspection of the home although it has been in operation for many years.

People’s experience of using this service:

We were aware, and people, their relatives and the staff told us, that in the past year Burrswood had been through several significant changes. The home had changed ownership, there had been three registered managers of the service and internal restructuring of the staff team. These changes had affected morale and confidence in most parts of the service.

We found that the new registered provider demonstrated a commitment to continuing to drive forward improvements at Burrswood Care Home. This was being achieved by additional senior management support, face to face practical training and support as well as investment into the home.

At this inspection we found seven breaches in the Regulations relating to staffing levels, the safety of medicines management, people’s individual risk assessments, staff training, care plans, activities, particularly for people living with dementia, quality assurance and record keeping.

The providers quality assurance audits and systems had not identified the shortfalls we found to ensure good governance of the service.

Systems in place did not ensure that people received their medicines in a safe way. The registered provider took immediate action to address our concerns, however we need to sure that improvements are maintained.

People’s care records we saw showed that individual risk assessments were not always in place to help ensure they received safe care and support, for example, monitoring food and fluid intake, choking and moving and handling assessments.

People where supported by staff who had been safely recruited. However, we had concerns about staffing levels afforded to people to ensure they receive safe, responsive and dignified support by consistent staff who knew them well. This was particularly on Peel House nursing dementia unit where high levels of agency staff were being used.

People were not supported by staff who had received training and support to provide safe and effective care. The registered provider was working swiftly to address this matter and had plans to develop training for staff.

People told us they enjoyed their food. However, on Peel House, Kay House and Dunster House the hostesses, who had previously taken time to assist and monitor people with their food and fluid intake, had been removed and not replaced by an additional member of staff as had been agreed. The registered provider told us that this matter would be addressed.

People’s records had not been kept under review. This is necessary to ensure that staff are aware of people’s needs. The registered provider had yet to introduce their care plans and risk assessments. They were aware that a significant amount of work to do to implement the new paper work and plans were in place to ensure that staff were supported to complete this work.

We found that there were not enough activity co-ordinators in place or the resources needed to provide people with meaningful activity to help support their physical and mental wellbeing, particularly on the units were people lived with dementia.

Staff had received training in safeguarding adults and knew what action they should take if they witness poor care or they thought a person was at risk. They were confident that the manager would act to ensure people were kept safe.

People lived in a clean and comfortable environment