The Burroughs

“The service was previously operated by a different registered provider. The service was registered with the current provider on 5 August 2025, and this was their first assessment.”

“We have rated the service requires improvement. We identified breaches of legal regulations relating to safe care and treatment and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.”

“ ”

“The provider had not always assessed, monitored or identified risks to people’s safety and wellbeing. We found equipment was not always working or clean. Staff completed risk assessments, but these were not always comprehensive enough or updated when people’s needs changed. Systems for managing medicines were not always safe. The environment was not always clean or well-maintained.”

“The provider’s systems for assessing and improving quality had not always been operated effectively. This meant that risks had not always been mitigated and records were not always clear or accurate.”

“We discussed our findings with the registered manager, and they developed an action plan telling us how they planned to make improvements.”

“Staff worked closely with external professionals to monitor and meet people’s healthcare needs. People were able to make choices about their care. Staff respected their decisions.”

“There were enough staff and people were cared for by the same familiar staff who knew them well. Staff completed a range of training and were supported to understand about best practice. However, some staff could not demonstrate their knowledge or how they would apply this. We discussed this with the registered manager who told us they could conduct a review of training needs. Staff felt supported and were happy working at the service.”

“The provider organised a range of social and leisure activities designed to reflect people’s interests. People were supported to remain independent when they wanted, and this was safe for them. People had information about the service and were able to share their experiences and feedback.”

“There were systems to learn when things went wrong, including responding to accidents, incidents and complaints.”