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 3 0 6 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 11 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 11 What we found:
The inspection was carried out to monitor the progress being made to meet the homes action plan, and requirements made at the key and random inspections carried out on the 19 February 2009, and 1 May 2009. At the start of the inspection we served the most senior person in charge with a Code B Notice, a procedure in line with Criminal Procedure and Investigations Act 1996, allowing inspectors to seize or copy any documents relevant to their investigation. The inspection focused on the areas of recruitment and selection, staff supervision, management and the reporting of accidents and incidents under Regulation 37 of the Care Homes Regulations 2001. We were given a copy of the organisations recruitment and selection procedure dated August 2006. This clearly sets out the procedure a manager should follow when recruiting staff including the need for an enhanced Criminal Records Bureau (CRB) check, two written references, properly completed application form including employment history and dates, evidence of identification and, if appropriate, work permits, visas and leave to remain permits. No new staff had been recruited since the last inspection on the 1 May 2009, but we did look at the staffing file for the most recently recruited person whose interview was carried out on the 14 April 2009. Records are kept in a standard way but are not always fully completed, we saw gaps in the application form, interview record and hand written references that had not been dated when received and it was not clear whether the candidate had brought them to the interview. We were given a copy of the reference request letter and form that a manager should use when obtaining references. The organisation has made the decision to no longer use the POVA First system to allow them to start new employees, working under supervision, before a full CRB report is received. Our requirement to follow proper recruitment and selection procedures will remain open until the next inspection so that we can properly check whether it has been met. We were provided with a copy of the latest supervision matrix and checked the records for six members of staff, selected at random, who should have had two supervison meetings since February this year. Notes were available for each of these people for February but a follow up meeting had not been held, putting the new schedule immediately behind. The schedule had also been set up for quarterly supervision meetings instead of bi-monthly.
Care Homes for Older People Page 4 of 11 The format for recording one to one meetings was appropriate and included a review of previous decisions or actions, workload, practice and performance issues, personal development, staff issues and an understanding of safeguarding. Those records seen had been completed in good detail, generally covered all the areas of the agenda, included comments about the direct observation of care delivery and were dated and signed by both the interviewer and interviewee. The supervision and appraisal policy is clear and forms part of the agreement signed by the supervisor and supervisee. We looked at the accident records covering the period 1 to 30 May 2009. Records were fully completed and where appropriate had been reported to CQC in a timely way as required by Regulation 37 of the Care Homes Regulations 2001. The manager is being given extra support to audit records making sure they are up to date, to identify training needs and to increase the number of senior staff who are able to take on the role of supervisee. What the care home does well: What they could do better: 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 5 of 11 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 6 of 11 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 The organisations 30/05/2009 recruitment and selection procedures must be properly followed. This will make sure that people who work in the home
Care Homes for Older People Page 7 of 11 01/05/2009 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 are properly screened, are not prevented from working with vulnerable people, helping to keep residents safe and well. 7 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. This help to protect residents from abuse. 8 29 19 Ensure staff are sufficiently 01/12/2008 screened and checked before recruitment. Residents are protected from harm by secure staff screening. 9 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. 10 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
Page 8 of 11 30/05/2009 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 performance to be reached. Better management of the home will improve standards of care and living for all residents. 11 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. 12 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. 30/05/2009 Care Homes for Older People Page 9 of 11 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 36 18 The frequency of staff 30/12/2009 supervision must be increased to meet the organisations target and National Minimum Standards. This will mean that people who work in the home get the support they need to do their job. 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 10 of 11 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 11 of 11 - 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!
