Inspection on 11/08/05 for Burn Brae Lodge

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burn Brae Lodge 08/01/09

Burn Brae Lodge 04/01/07

Burn Brae Lodge 31/01/06

Burn Brae Lodge 21/03/05

Burn Brae Lodge 03/11/04

Burn Brae Lodge 10/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Burn Brae Lodge Prospect Hill Corbridge Northumberland NE45 5RU Lead Inspector Allan Helmrich Unannounced 11 August 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Burn Brae Lodge Address Prospect Hill Corbridge Northumberland NE45 5RU 01434 632022 01434 634907 enquiries@burnbraelodge.co.uk Bridge Care Residential Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) P. Howard CRH 31 Category(ies) of DE(E) - Dementia - Over 65 (18) registration, with number OP - Old Age (13) of places Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: It has been agreed that a named service user who uses a self propelling wheelchair occupies a 16 square metre bedroom, in line with National Minimum Standards. No further admissions of service users who require self propelling wheelchairs should take place without prior agreement of the CSCI, due to the additional space required. Date of last inspection 21 March 2005 Brief Description of the Service: Burn Brae is a care home providing personal care and accommodation for 31 older people, some of whom have a dementia.The home is located in a rural setting approximately a mile from the village of Corbridge with no immediate access to any community facilities. The proprietor provides transport for visitors to the home and for any resident requiring a community service.Set in extensive landscaped grounds with a wood to one side and views over the Tyne valley on the other, the property consists of a large detached family house which has been extended.The home consists of 23 single bedrooms, 3 of which have en suite facilities and 4 double bedrooms, 2 of which have en suite toilet and hand basin. There is a passenger lift installed. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in one day. The inspection lasted 6 hours and in that time the opinion of visiting district nurses was obtained. Several residents and their visitors were spoken with. A tour of the premises was undertaken, the home’s records were reviewed and staff views were obtained. What the service does well: What has improved since the last inspection? What they could do better: Although the proprietor/manager supports a high standard of care, there is a lack of systems. Much of the work done is not structured and tends to take longer than necessary. Several requirements made at previous inspections are either not completed or in some cases have not been started. These are; • Manager’s quality checks of case records. Format produced but no action taken on the records checked at the inspection. • Provide vulnerable adult training for staff. Not started. • Produce a staff training plan and definitive training record. Not in place. • Install handrails throughout the building. In progress. • Provide privacy for residents whose bedroom windows are overlooked. Not completed. • Produce a protocol to avoid contamination of the water supply by the Legionella virus. This was not available for inspection. • Introduce a system of monitoring and improving the quality of care provided. Not in place. • Ensure each member of the staff team is provided with supervision at least 6 times per year. Not started. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 6. Appropriate information is obtained to limit the possibility of unsuitable placements being accepted into the home. Intermediate care is not provided in this home. EVIDENCE: The case records of five residents were reviewed and those belonging to newer residents contained a full pre admission assessment carried out before a place was offered. In addition to this information care managers assessments and information from appropriate professionals was obtained. The home does not provide an intermediate care service but vacancies may be filled by respite clients. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8. Some progress has been made with the home’s recording of residents needs in relation to health and personal care. These records vary in quality. EVIDENCE: Individual plans of care are available and some time has been spent recently in improving the quality of these files. One file contained well described care issues but these were not dated and had not been signed by the person who wrote them. Although some files contained regular evaluations this was not always the case. A management monitoring sheet has recently been included in the files but to date these are unused. Two district nurses in the home during the inspection commented that care provided in the home is good. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed at this inspection. EVIDENCE: Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18. Complaints are handled properly and residents are provided with the information they need to make a complaint. Appropriate vulnerable adult procedures were not available and staff are not trained in protecting people from abuse. EVIDENCE: An information pack containing details of the home’s complaints procedure is provided in the bedroom of each new resident. A complaints procedure is pinned to the home’s notice board for visitors to the home. Any complaints are recorded in a book maintained for matters of this nature with the details of how the complaint is resolved. No evidence was provided that the home has a copy of the local authority adult abuse procedures or the Department of Health guidance ‘No Secrets’. Other than the manager and one staff member, no one has been involved with adult abuse awareness training. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26. The home is reasonably clean although some offensive odours were evident. Some general improvements to the home are being made. EVIDENCE: The home is generally clean, although strong odours were noted in the entrance corridor to the home. A programme of works to cover radiators to protect residents is completed and work has now started on providing handrails throughout. A carpet in the lounge was heavily marked and should be replaced as cleaning has not had any effect. The privacy of residents whose bedroom windows overlook the front door and the rear patio is still not addressed although curtain material is now purchased. An air extractor found to be inoperative at the last inspection has now been removed but not replaced. Some new paths have been laid in the garden and seating provided. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30. The numbers of staff is sufficient to meet the current needs of the residents in the home. Staff training is ongoing. Recruitment procedures are not robust and induction for staff is not done formally. EVIDENCE: The staff rota demonstrated that staffing levels are appropriate for the current residents. During the inspection sufficient staff were available to meet the needs of residents. Currently only 5 of the 13 care staff have achieved the desired qualification level in care but three staff are nearing completion of NVQ level 2. Two staff files demonstrated that rigorous employment procedures are not followed. Neither staff member had completed the declaration asked for on the application, one appointment was not confirmed in writing and the home’s employment audit was incomplete. The records did not demonstrate an induction of staff had taken place or that a job description and code of conduct was provided. A training plan and record of training for staff was not available in the home. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, The manager is experienced and has worked in care homes for the elderly for many years. Various factors, including the problem of obtaining staff, limit the improvements required to meet the National Minimum Standards. Other than the proprietor’s regular presence in the home there is little quality monitoring conducted. Staff do not get supervision and meetings are not regular. Procedures ensure residents are reasonably safe in the home. EVIDENCE: Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 15 The proprietor has a Diploma in Social Work and is aware of the requirement to obtain additional units to achieve the Registered Managers Certificate. He has spent many years managing a local authority care home for the elderly and demonstrated a good knowledge of the needs of the group of residents at Burn Brae. His limitation is the time he is able to devote to management and systems improvement. Staff meetings are rare, supervision of staff that should be done 6 times per year is not in place and there is no system for quality assurance in place. The home is reasonably safe. A fire risk assessment is in place, fire checks are regularly done as is fire instruction for staff. Radiator covers are now in place on all radiators and a programme to ensure handrails are provided is underway. The requirement to produce a procedure for reducing the risks associated with Legionella was not available for inspection. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 1 x x 1 x 2 Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 Regulation 18(1)(a) Requirement Provide all staff with appropriate training related to the protection of vulnerable adults. This is an outstanding requirement. Attend to the following health and safety issues; Replace the stained carpet in the lounge. Review the method of transporting laundry that may be responsible for the strong odours in the entrance hall noted at the start of the inspection. THE FOLLOWING REQUIREMENTS ARE OUTSTANDING FROM PREVIOUS INSPECTIONS. Complete the installation of handrails throughout the building. Replace the air extractor recently removed from a bathroom. Provide privacy at windows overlooked at the front door and rear patio areas. Produce a protocol to avoid Legionella contamination of the water supply. Ensure the homes recruitment and induction process is appropriate. A recruitment audit form should be fully completed and a formal induction for each new employee should be in Timescale for action 30/11/05 2. OP19, OP26, OP38. 23(2)(c) 30/11/05 3. OP29, OP30 18, 19. 30/9/05 Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 18 4. OP33 24 5. OP36 18(2) place. The requirement from a previous inspection to produce a training plan and record of training should be addressed. Quality audit systems to review and improve the care provided should be initiated, This is a requirement from a previous inspection. Staff supervision must be introduced and staff meetings arranged to ensure that staff views are heard. 31/12/05 30/9/05 6. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7, OP8. OP28 OP31 Good Practice Recommendations Continue with the improvement to case records. Ensure information included is dated and that regular reviews are conducted by management. Continue with the programme to achieve 50 of staffing with NVQ level 2 or above by 31st December 2005. The manager should obtain the Registered Managers Award by 31st December 2005. Burn Brae Lodge B53-B03 S538 Burn Brae Lodge V237675 110805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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