Greater Manchester care home is rated inadequate and placed in special measures by CQC

Burrswood Care Home, which is run by Advinia Care Homes Limited, provides personal and nursing care to a maximum of 125 people.

 The inspection was prompted due to concerns received from relatives, intelligence from local stakeholders, and our own risk analysis regarding pressure wound care, staffing levels, management of falls and leadership.

Following the inspection, the overall rating for the home is inadequate, as well as the areas of safe, effective, caring, responsive and well-led. The service was previously rated requires improvement overall, and for being safe, responsive and well led. Effective and caring were previously rated as good.

The service has been placed in special measures which means it will be kept under close review to make sure people are safe and, if CQC do not propose to cancel the provider's registration, there will be a re-inspection to check for significant improvements.

Alison Chilton, CQC deputy director of operations in the north, said: 

“It was very concerning that there had been a systemic failure of leadership and management across all areas. This had caused a deep sense of mistrust between staff and management and led to a closed toxic culture which led to poor quality care.

“For example, the management of incidents, including falls, wasn’t safe. We identified multiple examples where people were known to be at risk, but there had been a failure to act to adequately mitigate those risks. We identified at least six examples where an incident hadn’t been referred to the local authority safeguarding team, and CQC hadn’t been notified either.

“The provision of activities and opportunities for people to follow their interests was poor. This was despite the provider charging an additional weekly fee for activities which is totally unacceptable.

“In addition, whilst it was evident some staff were caring and well intentioned, others appeared disinterested and didn’t pay attention or support people’s basic needs in a compassionate way. The individuality and diversity of people receiving care wasn’t acknowledged or celebrated in any meaningful way, which was particularly concerning for people with protected characteristics.

“We will continue to monitor the service closely to ensure urgent improvements are made. If we are not assured people are receiving safe care, we will not hesitate to take further enforcement action to ensure people are receiving the high standard of care they deserve.”
 

Inspectors found:

• The induction, training and development of staff was poor.
• There was a lack of qualified nursing staff with the relevant professional training, skills, and experience to effectively deliver care to people living with complex advanced dementia.
• People weren’t always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible.
• The environment, décor and design of the home wasn’t in line with national best practice guidance for supporting people living with dementia.
• There was too much of an inward focus and links with the local community were virtually non-existent.
• Governance systems weren’t operated effectively and weren’t fit for purpose.
• Some people's health was placed at risk of harm because their medicines were unavailable or out of stock.

The report will be published on CQC’s website on Wednesday 25 October.