Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 31/01/06 for Burn Brae Lodge

Also see our care home review for Burn Brae Lodge for more information

This inspection was carried out on 31st January 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Care is provided in a homely setting. Residents provided limited information during the inspection but those that did comment were complementary about the service. One visitor spoke highly of her dealings with the home.

What has improved since the last inspection?

Residents case records are being improved, work is still ongoing. Improvements to the home are ongoing; all radiators now have covers and handrails have been provided throughout the home. Overlooked bedrooms now have privacy curtains in place. A new staff induction is in place and is being trialled on two recent recruits. Improved communication is provided with staff meetings and one to one meetings with management now in place.

What the care home could do better:

The proprietor/manager has yet to obtain the Registered Managers Award. Not all staff have been provided with abuse awareness training. A staff training record and training plan are being developed by the proprietor/manager. This should be concluded for all staff. The quality assurance plan should be further developed to involve staff, residents and visitors to the home.

CARE HOMES FOR OLDER PEOPLE Burn Brae Lodge Prospect Hill Corbridge Northumberland NE45 5RU Lead Inspector Allan Helmrich Unannounced Inspection 31 January 2006 10:45 X10015.doc Version 1.40 Page 1 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 Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 2 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 DS0000000538.V275963.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burn Brae Lodge Address Prospect Hill Corbridge Northumberland NE45 5RU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01434-632022 01434-634904 enquiries@burnbraelodge.co.uk Bridge Care Residential Limited Mr P Howard Care Home 31 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (13) of places Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 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 are en suite. There is a passenger lift installed. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second annual inspection. It took 4 hours and in that time I spoke with several residents. Management and staff were interviewed, a selection of records maintained in the home were reviewed and there was a general tour of the building. One visitor who intends to place her relative was spoken to for her opinions of the home. What the service does well: What has improved since the last inspection? What they could do better: 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 DS0000000538.V275963.R01.S.doc Version 5.1 Page 6 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 Outcomes Statutory Requirements Identified During the Inspection Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 7 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 the following standard(s): None of these standards were assessed at this inspection. EVIDENCE: Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 7, 8, 9, 10. Each resident has a plan of care that is currently being improved. Health assessments are in place and a record of any healthcare provided is recorded. The medication system is generally satisfactory. Staff are respectful to residents. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 9 EVIDENCE: Each resident has a plan of care that has recently been updated. The records include a recent photograph and the residents preferred name. The manager has reviewed each record and made comments on areas requiring improvement. Key workers collect information on a monthly basis and produce a summary. This did not always include the elements of care identified in the original assessment. A record is kept of all healthcare interventions and individual health assessments are reviewed periodically. The system of storage, recording and dispensing medicines is appropriate with the exception of those medicines that are refrigerated. These should be retained in a locked box within the refrigerator. All staff dispensing medicines have been provided with appropriate training. Staff were observed being respectful with residents. Residents’ permission is obtained before entering bedrooms and personal care is provided in private. The proprietor reinforces attention to detail with respect to residents privacy and dignity during staff induction and at other times. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15. Residents are provided with some stimulation. Visitors are made welcome and community groups are encouraged. Information regarding advocacy is provided and independence is promoted. The home provides wholesome food. EVIDENCE: An activities schedule on the home’s notice board is not followed. Ad hoc activities do take place but these are not recorded and no details of who takes part are available. Each week a keep fit instructor visits the home to lead the residents through age appropriate exercises and a hairdresser visits weekly also. Residents are supported to shop locally. Three daily newspapers are delivered to the home each day and a small library and some board games are available for residents use. Regular services take place with ministers from the Catholic, Church of England and Methodist church’s. One resident visits a bible group and another attends Jehovah meetings. A visitor confirmed she was made welcome in the home. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 11 Residents’ bedrooms were noted to contain personal possessions ranging from small mementos to large items of furniture. The manager stated that currently all residents have family supporters, however, the Alzheimer’s society visits the home and the notice board contains details of advocacy services. During the inspection residents were seen eating a substantial meal and drinks were provided throughout the day. The kitchen is clean and appropriately equipped and sufficient food is available to provide substantial alternatives to the menued choice if requested. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 18. Residents are protected from abuse by some trained staff. EVIDENCE: Since the last inspection a further four staff have been provided with abuse awareness training. Local authority procedures for the protection of vulnerable adults are available to staff but not the Department of Health guidance ‘No Secrets’. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19, 26. The home is clean and reasonably well maintained. EVIDENCE: The home is generally clean and no offensive odours were noted. Since the last inspection the programme to provide handrails throughout the home has been completed, net curtains are provided at all windows overlooked at the front of the building and from the rear patio. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 14 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29, 30. 50 of the staff team are trained to NVQ level 2 or above. The recruitment process is improved and a training programme is in place for new recruits and other staff. EVIDENCE: 7 staff have attained a National Vocational Qualification (NVQ) at level 2 in care. The recruitment processes in the home have improved, an audit sheet is used to demonstrate appropriate procedures for employing staff are followed. New staff are being inducted using a certified training programme and this is followed by further training to meet the needs of older people. A record of training is produced and maintained for all staff. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 15 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. The manager is experienced and has worked in care homes for the elderly for many years. A system of quality assurance is not in place. Monies held on behalf of residents are appropriately detailed. Staff supervision and meetings are now in place. Procedures ensure residents are reasonably safe in the home. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 16 EVIDENCE: 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 care homes for the elderly and demonstrated a good knowledge of the needs of the group of residents at Burn Brae. Recently he has introduced staff meetings and one to one supervision sessions with the staff team. Other than the manager/proprietors regular presence in the home, a system of monitoring the quality of care provided is not in place. The manager is aware of this requirement and is currently developing a system that takes account of residents and visitors comments. 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 and handrails are provided throughout the home. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 17 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 x X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? yes 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 OP9 Regulation 13(2) Requirement Comply with pharmacy guidance and ensure all medicines are locked away, including those that are refrigerated. Timescale for action 28/02/06 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 5 Refer to Standard OP7 OP12 OP18 OP31 OP33 Good Practice Recommendations Continue with the improvements to the care planning system. Review the activities provided in the home and provide a system for ensuring that appropriate activities are available and recorded. Continue providing abuse awareness training for staff. The manager should obtain the registered managers award. Continue with the development of a quality assurance system. Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Cramlington Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Burn Brae Lodge DS0000000538.V275963.R01.S.doc Version 5.1 Page 20 - 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!