Bury: Burrswood Care Home rated inadequate by watchdog

Burrswood Care Home on Newton Street was inspected on August 1, 2023, by the Care Quality Commission (CQC).

The safety, effectiveness, caring, responsiveness and how well led the service is were all rated as inadequate and the service has been placed into special measures.

Burrswood provided personal and nursing care to 75 residents at the time of inspection and the report stated that some of the concerning things they witnessed were medicines not being managed properly, management of witnessed and unwitnessed incidents, including falls, was not safe and deployment of staff was disorganised and frequently chaotic.

It also said that the induction, training and development of staff was inadequate and there was a distinct lack of qualified nursing staff with the relevant professional training, skills, and experience to effectively deliver nursing care.

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In regard to the safety of the service, it was found that residents were put in an increased risk of harm due to unsafe management and administration of medicines.

The report also added: “We identified multiple examples where people had known to be at risk, but there had been a failure to act to adequately mitigate those risks.

“For example, one person had suffered eight separate untoward events, some of which required hospital treatment, but there had been a failure to properly risk assess and to make external referrals to appropriate agencies.”

Inspectors also identified at least six examples where an accident, incident, untoward event or altercation between residents had occurred and had not been referred to safeguarding or notified to the CQC.

Each of the incidents were known to staff but there had been a failure of internal reporting and management oversight.

Infection prevention and control measures were found to not be consistent or robust and parts of the care home was said to look visibly unclean.

The report said: “A scabies outbreak was confirmed at the time of this inspection, but this was not managed well by the provider.”

Read more: Jewish social care organisation rated 'outstanding' by CQC

Regarding the effectiveness of the service, the food and drink offer across the home was described as poor.

The report said: “Feedback remained negative with comments including "It's just beige food all the time, like chips and pizza.

“We hardly get any fresh vegetables and I think fresh fruit is considered a treat!" and, "I just don't know how they can consider this food to be nutritious.

“My [relative] has never eaten this type of food and often doesn't want to eat it. I worry about them losing weight."

The report also added communication between staff and primary care services was poor.

It said: “Primary healthcare professionals told us they often did not have confidence in reporting their findings verbally to staff, therefore would send written information separately, for example, via email.”

Read more: GMMH NHS Foundation Trust rated 'inadequate' by CQC

In terms of leadership, at the last inspection it was rated this key question requires improvement. At this inspection the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in service leadership.

Leaders and the culture they created did not assure the delivery of high-quality care.

The report said: “There were serious failings to safeguarding people at risk of abuse or neglect.

“When things went wrong, the provider, registered manager and others in key roles of responsibility within the home, had not been open, honest or transparent.”

It also stated: “There had been a systemic failure of leadership and management across all areas.

“There was a deep sense of mistrust between staff, the registered manager, deputy manager and senior managers acting for the provider.

“This led to a closed toxic culture amongst staff which led to poor quality care.”

Due to these findings, Burrswood has been placed into special measures and will be re-inspected in six months’ time.

Alison Chilton, CQC deputy director of operations in the north, said: “When we inspected Burrswood Care Home, it was concerning to see such a significant deterioration in the quality of care being provided.

"Leaders need to prioritise making urgent improvements, particularly regarding how the service is run, to ensure people’s needs are properly met.

“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."

Burrswood Care Home was previously placed in special measures in December 2021 after the CQC judged its services to be inadequate. In July 2022, the watchdog upgraded the care home’s rating to "requires improvement". 

A spokesperson for Burrswood said: "The safety and wellbeing of our residents is our highest priority, and we are committed to providing the very highest quality care at Burrswood Care Home.

"We are of course hugely disappointed with the findings of the most recent Care Quality Commission report into the service.

"The senior leadership team have already formulated and implemented a robust action plan to address the relevant concerns and we are confident that the service is already feeling the benefit of these changes.

"We have long known that the care needs of many residents had increased, and we had raised this issue with the local authority to urge them to provide more funding so the appropriate level of care could be provided.

"Sadly, this was not forthcoming, despite repeated requests. We believe this lack of funding was a contributing factor to this report.

"As a team we remain committed to our residents, and their families, and we thank them for their patience during this time."

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