This inspection was carried out on 1st May 2009.
CQC found this care home to be providing an Adequate service.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Briardene Care Home Newbiggin Lane Westerhope Newcastle upon Tyne NE5 1NA one star adequate service 16/02/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Elaine Charlton Date: 0 1 0 5 2 0 0 9 Information about the care home
Name of care home: Address: Briardene Care Home Newbiggin Lane Westerhope Newcastle upon Tyne NE5 1NA 01912863212 01912866820 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Windmill Hills Ltd care home 59 Number of places (if applicable): Under 65 Over 65 31 28 dementia old age, not falling within any other category Conditions of registration: Date of last inspection Brief description of the care home 0 0 1 6 0 2 2 0 0 9 Briardene is a care home with nursing providing care for older people with physical and mental health needs. The home is owned and managed by Windmill Hills Limited that is part of a larger group, which provides care services for a variety of client groups. The home is staffed by registered general nurses supported by care staff. The philosophy of care is to support the residents in their activities of daily living and to provide for their physical and mental health needs. The home is situated in Newbiggin Lane in the west of the city of Newcastle upon Tyne fairly close to local shops and public transport links. The building is comprised of three floors, the top floor being staff accommodation. The lower two floors are resident
Care Homes for Older People Page 2 of 12 Brief description of the care home accommodation with 62 single bedrooms all with en-suite facilities. On each of these floors there are a number of bathrooms, toilets, lounge and dining rooms. The home has a visitor coffee room and hairdressing room. There is also a kitchen and laundry room. To the rear of the home there is a very nice garden and patio area. Fees in the home vary and are available on request from the organisation. Care Homes for Older People Page 3 of 12 What we found:
The inspection was carried out to monitor whether requirements made at an inspection on the 19 February 2009, to support the proper recruitment and selection of staff working in the home had been met. It was also prompted by an incident invoving a person employed in the home that we were alerted to by the Local Authority. At the start of the inspection we served the manager with a Code B Notice, a procedure in line with the Criminal Procedure and Investigations Act 1996, allowing inspectors to seize or copy any documents relevant to their investigation. The registered manager was given the opportunity to read our guidance setting out the providers rights when a Code B notice is served. She alerted the company Operations Director to the inspection. The Operations Director had provided the Commission with an action plan setting out how, and by when, the requirements from the previous inspection would be met. This was received on the 9 April 2009. In relation to staffing it stated the recruitment procedure has been revisted by the homes manager and a full audit of the staff personal files had been previously undertaken but a further audit will be carried out. No staff member will be employed without the correct screening taking place. If Criminal Records Bureau (CRB) checks are returned with evidence of a police history then this will be discussed with the employee and evidence on how the decision has been reached to employ this person will be held on file. The date for completion of a further file audit was given as 30 April 2009, and for proper screening checks, immediately. We looked at the records for four members of the staff team. Three who had been recently recruited and the member of staff involved in the safeguarding referral. The three recently recruited staff had started work between the 23 March and the 14 April 2009. Each person had completed an application form but dates of previous employment only showed the month and year of employment or only the year. This meant that any gaps in a persons employment were not easily identifiable and may not have been followed up. Two references were available for each person but it was not clear whether these had been requested by the provider or whether the person had brought them to interview with them. A reference from a previous employer was not always available. For one person their reference had been given by one of the other applicants just starting work. CRB and POVA First checks are carried out. Responses are received at head office and a telephone call is made to the manager to tell her that it has arrived. This is then recorded
Care Homes for Older People Page 4 of 12 in a register in the home. We were told that if there are any disclosures returned by the CRB this is passed on to the manager for further checking. For the other member of staff whose records we looked at and who had started work in July 2008, their CRB check was not returned until November 2008. During this period there was no clear evidence that the person was working in a supervised position, they had covered shifts at a sister home that would have required them to work alone, they had been promoted from care assistant to senior carer, had not properly and fully completed the disclosure section on their application form and had attended Court to answer several charges without advising the provider. When the CRB disclosure for this person was returned to the provider the manager did carry out an interview and made the decision for the persons employment to continue. There was no written evidence of the content of this interview, no written statement from the employee, and no statement from the manager about how she came to the decision to continue the persons employment. Although the fourth member of staff had worked in the home since July 2008, their first documented supervison session did not take place until 1 January 2009. This member of staff had also made two requests to transfer out of the home during the period July 2008 to May 2009. The organisation uses an interview form and scoring system for new applicants. This states that a person who scores 13 or less is unlikely to be employed. One person had only achieved a score of 14, but there was no additional evidence provided to say why the person carrying out the interviews felt they would be a valued member of the team. The incident involving a resident and a member of the staff team that we were told took place on the 19 April 2009, was not notified to the Commission until the 24 April, after the home had been reminded to do this by the safeguarding team. What the care home does well: What they could do better:
Ensures that the organisations recruitement and selection procedures are properly carried out and provide the evidence outlined in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001. Properly follow up and document any gaps in a persons employment history, disclosures made on their application form or CRB disclosures. Make sure that people who have only had a POVA First check carried out do not work unsupervised.
Care Homes for Older People Page 5 of 12 Clearly document and date all shadowing arrangements for staff carried out as part of their induction. Make sure that a regular programme of recorded supervision is in place and carried out supporting staff to do their job and helping to identify any issues of concern about performance and development. Report accidents, illnesses and incidents to the Commission in a proper and timely way. The organisation must review the skills and training needs of the manager to help them carry out their role and to protect the health and well being of people living in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 6 of 12 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 7 15 Ensure that care plans give 01/04/2009 consistent information. Ensure all plans reflect the actual needs of residents and are person centered. Ensure food, fluid and weight records are properly completed. This will ensure that all residents care needs are properly identified. 2 9 13 All medication must be 01/05/2009 administered as prescribed and a supply must always be available to support this. All medicines must be stored safely and securely and at the temperature recommended by the manufacturer. Best practice guidance and the providers medication policy must be followed when recording all medicines. The controlled drug cupboard should be relocated and fastened to a solid wall. All staff who administer medicines must be formally assessed as competent to do so and a record made of their assessment. This will ensure that people Care Homes for Older People Page 7 of 12 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action receive their medication correctly and the treatment of their condition is not affected. This makes sure that medicines are not tampered with and remain safe to use. This will help make sure that peoples health and welfare are protected from the risk of medication errors and omissions. 3 15 16 Ensure that residents have 01/04/2009 access to nutritious food that is well presented and served at a temperature that suits them. Residents health and social needs are met at mealtimes. 4 16 22 Ensure that all complaints 01/04/2009 are taken seriously and acted upon over a period of time. This ensures that all improvements made are sustained. 5 18 13 Ensure all staff receive regular training in adult protection. This helps to safeguard residents from abuse. 6 29 19 Provide evidence that staff 01/04/2009 have been thoroughly screened prior to employment. Where staff are employed there must be evidence as to how that decision has been reached.
Page 8 of 12 01/05/2009 Care Homes for Older People Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action This help to protect residents from abuse. 7 29 19 Ensure staff are sufficiently 01/12/2008 screened and checked before recruitment. Residents are protected from harm by secure staff screening. 8 31 13 Provide an action plan 01/04/2009 indicating the measures put in place to improve the management of the home. Provide confirmation of the supervisory arrangements in place for the manager, include targets of performance to be reached. Better management of the home will improve standards of care and living for all residents. Care Homes for Older People Page 9 of 12 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 29 19 The organisations 30/05/2009 recruitment and selection procedures must be properly followed. This will make sure that people who work in the home are properly screened, are not prevented from working with vulnerable people, helping to keep residents safe and well. 2 31 9 The performance and training needs of the manager must be reviewed. This will mean that the organisation is sure procedures are properly followed and people living in the home are kept safe and well. 30/05/2009 3 36 18 A programme of staff supervision must be put in place and carried out. This will support people to do their job and help to keep residents safe and well. 30/05/2009 Care Homes for Older People Page 10 of 12 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 4 38 37 Accidents, illnesses and 30/05/2009 incidents must be properly reported to the Commission. This will make sure that proper procedures are followed and appropriate people are kept informed regarding the health and well being of residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 11 of 12 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 12 of 12 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
