Inspection on 04/01/07 for Burn Brae Lodge

This inspection was carried out on 4th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 31/01/06

Burn Brae Lodge 11/08/05

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 Key Unannounced Inspection 4th January 2007 10:30 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.V304607.R01.S.doc Version 5.2 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.V304607.R01.S.doc Version 5.2 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 01434-634907 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.V304607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 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 that 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 DS0000000538.V304607.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual unannounced key inspection visit. The inspection was conducted over two separate days and took 81/2 hours. Time was spent talking to the deputy manager, some care staff, several residents and a visitor. Some of the home’s care records were reviewed and the systems that maintain residents safety. Also as part of the inspection the care plans for three residents were inspected against the actual care provided. This is called ‘case tracking. Questionnaires were provided for residents and visitors to the home and the information provided was used in the production of the report. Seven responses were received. What the service does well: What has improved since the last inspection? Some work has been done to improve management systems. Care plans are improving and some quality monitoring is taking place. The manager has looked at privacy issues in the home and some windows have been fitted with net curtains. Staff training is ongoing although a change in the staff team means the percentage of staff with NVQ has reduced. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care is taken to ensure that residents’ needs can be met before a place is offered. Intermediate care is not offered. EVIDENCE: The case records of four residents were reviewed. Each contained a full pre admission assessment done by management before a place was offered. In addition to this information care managers’ assessments and information from appropriate professionals was obtained. This reduces the possibility of an unsuitable placement. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 9 One resident and her relative said they had recently moved into the home and her relative said that management and staff have been very good in making them feel welcome. All five visitors’ questionnaires returned before the inspection confirmed they are made welcome in the home and one of two residents questionnaires stated they received enough information before making Burn Brae their home. The home does not provide an intermediate care service but respite clients may fill vacancies. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ are well cared for and their health and care needs are well met. A reasonable system for administration of medicines is in place. Residents’ privacy and dignity could be improved. EVIDENCE: Several residents with limited communication abilities were seen in the home’s lounges and conservatory. They all appeared in good health with their personal care needs addressed. Residents spoken to were content with the care provided. One resident said that see feels healthy and that she often helps staff with light domestic jobs around the home. Appropriate equipment such as pressure mattresses are available in the home to support residents physical needs. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 11 Four care plans reviewed contained assessments done by management regarding nutrition, risks of falls and pressure area care. The information was reviewed regularly to ensure it is current and local authority funded residents have reviews done to ensure the care is appropriate. Privately funded residents do not get a formal review. Throughout the day the staff team demonstrated good practice in relation to respecting residents privacy and dignity. This is supported by comments made by residents. One bedroom in the home is currently shared occupancy and a screen is available should privacy be required. During a tour of the outside of the home a privacy/dignity issue was observed, however a member of care staff quickly addressed the situation by closing the room curtains. Residents are provided with use of the home’s phone in the manager’s office for incoming or outgoing calls. Everyone is offered the post that comes into the home for them, however at the moment only three residents currently open their own post and ask staff to assist them to read the contents. Other post is either kept for the family or for healthcare and other appointments the home deals with these. The system for recording and administering medicines in the home was checked and found to be appropriate to ensure residents health is maintained. Staff are trained and appropriate policies and procedures are in place to assist them. A lockable box in the fridge is available should the home need this facility and a system is in place for recording medicines that are on the controlled register. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treat as individuals and the staff team provides some stimulation. Visitors are made welcome and community groups are encouraged. Residents are encouraged to personalise their private space and assisted to do what they want to do. The home provides wholesome food. EVIDENCE: 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. Staff talk to residents throughout the day and one resident who enjoys being active was helping staff generally around the home with small tasks. Transport is arranged for residents who shop locally. Three daily Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 13 newspapers are delivered to the home each day and a small library and some board games are available for residents use. Four residents were sitting in the lounge and each said they were happy and did not want to do anything else. Two residents were in the conservatory having their hair done. They both said they enjoy this. One resident in her bedroom said she joined in some activities in the home and that she quite liked to chat to her relative and the staff on duty. Each residents preferences are recorded and the home attempt to ensure these preferences are met. Various church groups have been contacted to enable people to keep their faith and if transport is required then this is made available. Regular services take place with ministers from the Catholic, Church of England and Methodist church. One resident visits a bible group and another attends Jehovah meetings. The home management recognise that improvements to activities could be made and have provided a staff member with training related to this area of care. A visitor said he is always made welcome in the home and that he was encouraged to personalise the bedroom of his relative. Several residents’ bedrooms were noted to contain personal possessions ranging from small mementos to large items of furniture. The deputy manager stated that currently all residents have family supporters. 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. Tables were set in the dining room and a lounge and sufficient staff were at hand to assist those residents that needed it. All the residents that commented said they enjoyed the meal. The kitchen is clean and appropriately equipped and sufficient food is available to provide substantial alternatives to the menu choice if requested. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by trained staff that care about complaints and the protection of vulnerable people. EVIDENCE: The home’s complaint process is clearly written. It is provided to all new residents in a home’s brochure and is on the home’s notice board. One complaint made since the last inspection was recorded in a log with how it was addressed to the satisfaction of the family making the complaint. Staff spoken to said they would pass any complaints directly to management and the visitor spoken to said he had no complaints but if he had he would inform the manager. Management are aware of how to refer anything that affects the wellbeing of residents and staff have received recent training in abuse awareness. Policies and procedure are available to staff together with local and health authority guidance. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe and reasonably well maintained for the comfort of residents. EVIDENCE: The home is generally clean with no offensive odours. Changing the way soiled laundry is transported has eliminated odours noted at a previous inspection. A programme of works is in place to provide additional en-suite facilities in some bedrooms. Residents and a visitor spoken to said the home is comfortable and homely. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 16 The laundry contains appropriate equipment to meet disinfection standards. Laundry was being washed at the correct temperature and an instruction sheet to inform staff was fixed on the wall. Not all widows that are overlooked have net curtains. This caused the privacy/dignity issue identified earlier in the report. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team are caring and provide a good service for residents. The recruitment and training of staff is not recorded in enough detail to demonstrate residents are safe. EVIDENCE: Throughout the day staff were seen talking with residents, attending to their concerns and needs and generally providing a happy caring environment for the residents and their visitors. In the previous year, 10 staff have left the home and been replaced. Currently there are no staff vacancies and when they do exist the proprietor/manager and his deputy regularly cover shifts to ensure there is a full staff compliment to care for residents. A staff rota covering four weeks confirmed that appropriate levels of staff were in the home to care for residents needs. The manager has a training plan and has recorded staff training on a matrix. The dates of training are not included. Recent training for staff has included; infection control, dementia, team working and diabetes, epilepsy and visual awareness. One member of the staff team has attended training related to Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 18 providing stimulating activities in the home. This training should improve the standard of care for residents. Only four of the thirteen care staff have a NVQ in care, however there is a plan in place to train the rest of the staff team. Four files of staff employed since the last inspection were reviewed. All contained audit sheet identifying the process of employment. The files generally contained sufficient information to identify the person, two references and criminal records bureau checks (CRB) are obtained. The files did not demonstrate that a good induction took place and issues identified in CRB’s were identified and discussed by the employer. A random inspection conducted in September 2006 identified the need to produce an assessment of skills. A comprehensive induction (not found for new recruits) forms part of this process. One member of staff spoken to could not remember receiving a comprehensive induction. She has not had a training and development assessment or 1-1 meeting with management. These are considered essential in providing good care for residents. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced manager who has worked in care homes for the elderly for many years cares for residents. A system of quality assurance is being developed to monitor the standards of care provided. Monies held on behalf of residents are appropriately detailed. Procedures ensure residents are reasonably safe in the home. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 20 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 has recently introduced some quality monitoring into the home to help improve the standards of care for the residents. Recently the manager developed questionnaires and 29 were sent to people associated with the home. They have not all been returned but those that have were generally positive about the care provided. Some issues were identified and the manager has informed the staff team in a meeting of these and how they are to be resolved. Some new systems have been introduced. Care plans are improving and an audit sheet for staff files has been produced. Some improvements have been made to the premises with some windows now having privacy nets and some rooms are being fitted with en-suite toilet and hand basin. Radiator covers are now in place and handrails are provided throughout the home. Staff meetings to keep staff informed have started and most staff have now had a 1-1 with management. Residents and their families are encouraged to maintain their own finances. However a system is in place to hold monies for residents if requested. A log is maintained and two signatures are required at each transaction. A receipt is obtained whenever staff purchase anything for a resident and management regularly audit the accounts. A fire risk assessment was done in 2005, this should be reviewed. Fire checks are regularly done as is fire instruction for staff. Hazardous substances are safely stored and equipment is regularly serviced for the safety of the residents. All staff receive health and safety training and the home has policies and procedures to instruct staff in ensuring residents are kept safe. Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 3 17 X 18 3 3 X X X X X X 3 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 2 X 2 X 3 X X 3 Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 22 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 OP30 Regulation 18(1)(c) (i) Requirement All staff should receive a full induction signed by a competent person within 6 weeks of their appointment. A record of this should be available for inspection. Timescale for action 31/03/07 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. Refer to Standard OP7 Good Practice Recommendations Conduct a formal review of care with all residents including those who are self funding on an annual basis. Relevant supporters should be invited to attend. A further review should be undertaken regarding windows that are overlooked from outside of the home. Any windows where privacy is an issue should be fitted with curtains that obscure the view. 2. OP10 Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 23 3. OP12 Improve the quality and quantity of activities in the home. Each resident should be provided with the type of activities they enjoy. Staff training should continue to ensure 50 of the staff team obtain a NVQ level to or above. Before employing staff, the manager should review the information provided in CRB returns and make a judgement as to whether residents are safe. The training matrix recently produced should include the dates the training was done. The proprietor/manager should obtain the registered managers award. Continue with the development of a quality assurance system. Produce a plan of improvement with dates included. 4. 5. 6. 7. 8. OP28 OP29 OP30 OP31 OP33 Burn Brae Lodge DS0000000538.V304607.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V304607.R01.S.doc Version 5.2 Page 25 - 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. 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