CQC report explained · a nursing home
What the CQC found at Braeburn Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe, and there were enough staff to meet people's needs. Risks, medicines and infection control were managed safely, although some records about wound care and PEG care were incomplete.
- Effective?
- Good
- Staff had induction, training and supervision. People received suitable food, drinks and health support, but wound care records did not always follow the home's policy.
- Caring?
- Good
- People and relatives described staff as kind and caring. Staff supported choices, privacy and dignity, although inspectors saw one occasion when staff did not notice quickly that a person was struggling at lunch.
- Responsive?
- Good
- People and relatives were involved in care planning, and activities and communication support were provided. Some care plans lacked detail, including information about distracting people with dementia and what to do if a PEG tube became blocked.
- Well-led?
- Good
- The manager was visible and approachable, and people knew who to speak to about concerns. Audits, meetings and feedback systems were used to monitor and improve care.
What inspectors found, February 2020
Braeburn Lodge is rated Good; inspectors found kind, safe care, but some wound and feeding-tube records were incomplete.
Inspectors made an unannounced visit on 26 November 2019. They spoke with people living in the home, relatives and staff. They observed care and checked care records, medicines records and management documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training and care that generally respected people's choices, dignity and individual needs.
There were gaps in recording wound care and care for people with PEG feeding tubes. Some care plans also lacked detail. The managers took immediate action during the inspection to address these issues. The previous rating, published in April 2017, was also Good.
Enough staff
Inspectors found staffing levels were above the number identified as needed. Staff were available to support people, including people who might not be able to use a call bell.
“There were enough staff to meet people's needs.” from the report
Kind and respectful care
People and relatives described staff as caring. Staff supported people's choices and took steps to protect privacy and dignity.
“Staff understood how to provide care which protected people's privacy and dignity.” from the report
Staff training
New staff received an induction, shadowing and competency checks. Ongoing training included medicines, infection control and other care skills.
“Staff had ongoing training and supervision to ensure their skills remained up to date.” from the report
Incomplete wound records
needs fixingWound care records did not always contain up-to-date instructions, photographs or measurements. This made it harder to judge whether wounds were healing.
“The instructions section was frequently not up to date. In addition, the wounds were not photographed or measured, thus making it difficult to assess whether the wound was reducing in size or healing was progressing.” from the report
PEG care plans lacked detail
needs fixingSome care plans did not explain what staff should do if a PEG tube became blocked or give contact details for specialist advice. Nurses knew what to do, and the provider began putting a new document in place.
“Care plans did not always contain detailed information on the care people with a percutaneous endoscopic gastrostomy (PEG)” from the report
Care plans were sometimes too general
minorSome plans did not give enough personalised information, such as what worked when a person living with dementia became distressed. Staff generally knew people's needs in practice.
“Some care plans were variable in the amount of information included and were not always as detailed as they could have been.” from the report
Staff did not always notice when help was needed
needs fixingInspectors saw one person struggling at lunchtime. Staff helped only after other people at the table called for assistance.
“Staff had failed to notice one person was struggling at lunch time.” from the report
Changes to nurse arrangements
minorNurses had been redeployed so there was one on each floor. Staff said the upper-floor workload had increased, and some relatives found it harder to find someone to ask about their relative.
“Relatives of people living with dementia told us that the change had made it more difficult to find a member of staff when they wanted to ask about their loved one's welfare.” from the report
- 01How are wound records now checked to make sure instructions, photographs and measurements are complete?
- 02What written guidance is now available for PEG care, including what staff should do if a tube becomes blocked?
- 03How do you make sure care plans contain personalised information about what helps each person, especially people living with dementia?
- 04How do staff identify quickly when someone needs help during meals or in communal areas?
- 05After the nurse rota changes, who should families speak to about a relative's health or care, and how quickly can they expect an answer?
This was an unannounced comprehensive inspection covering all five key questions, including the care and premises provided by the home. This explanation was written from the published report of 12 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2017
Braeburn Lodge was rated Good overall; inspectors found kind, safe care, with some staffing and record-keeping issues still being addressed.
This was an unannounced inspection on 8 March 2017. Two inspectors and an expert by experience visited the home. They spoke with people living there, relatives and staff, observed care, and checked care records, staff files, training records and quality checks.
All five areas were rated Good: safe, effective, caring, responsive and well-led. People said they felt safe and staff were described as kind, respectful and supportive. Inspectors saw staff responding to calls, helping people maintain independence and supporting activities, hobbies and religious beliefs.
There were some areas still needing improvement. People and staff had mixed views about staffing, and there were vacancies. Food and fluid records were not always completed consistently, some fluid targets were out of date, and some staff needed more training. Some care records and formal staff supervision also needed further work.
The overall Good rating means inspectors found the home meeting the relevant standards at the time of this inspection. The report also says improvements had been made since the previous inspection in November 2015, while an action plan was still being carried out.
Kind and respectful staff
Inspectors observed caring interactions and found that staff knew people's interests, histories and needs. People said staff respected their privacy and dignity.
“All interactions we observed throughout the visit were encouraging, kind and caring.” from the report
Personalised choices
Care records included detailed preferences, such as routines, food, pillows and preferred carers. Staff supported people to make choices about daily care.
“These included preferences such as the choice of carers; food and drink; times they liked to go to bed and get up, and even how many pillows they preferred at night.” from the report
Activities and interests
People were supported to take part in outings, music, exercise, church services and other activities. Staff also considered people who preferred individual or quieter activities.
“People led very active lives and they were supported to maintain hobbies and interests.” from the report
Improved risk management
Inspectors found improvements since the previous inspection in how individual risks were recorded and monitored. Equipment and professional support were used to reduce risks such as falls and pressure damage.
“At this inspection visit we found that improvements had been made.” from the report
Medicines managed safely
People received medicines when needed and staff followed a careful process. Records, secure storage, training and checks were in place.
“There were safe medicine administration systems in place and people received their medicines when required.” from the report
Staffing pressures
needs fixingPeople and staff gave mixed views about staffing. The home had vacancies and was using agency staff, although inspectors saw staff responding to calls and the manager was recruiting.
“People living at the home and staff had mixed views about whether there were enough staff to meet people's needs.” from the report
Food and fluid records
needs fixingSome food and fluid diaries were difficult to follow. Fluid targets had not always been updated when people's weight changed, and some records did not explain what staff should do if intake was too low.
“However, some of these records were difficult to follow as they were inconsistent in the way they had been completed by staff.” from the report
Care records needed updating
minorSome care records were inconsistent or missing information about activities and reviews. The manager had started a review of all records.
“There were still elements of improvement needed; however there was an action plan in place to achieve this.” from the report
Formal staff supervision
minorOne staff member had not received formal supervision, and audits had identified this as an issue. Observational supervision and a plan for more formal support were in place.
“One staff member told us that they had not received supervision, this is a one to one meeting where staff can talk about their roles and any development support they may need.” from the report
- 01How many care staff are now on duty on each shift, including at night, and how many agency staff are being used?
- 02How do you now check that food and fluid diaries are completed consistently and that fluid targets are updated when someone's weight changes?
- 03What progress has been made in reviewing and updating all care records?
- 04How are staff supervision and appraisals now arranged and monitored?
- 05What action was taken after the increase in safeguarding incidents in the dementia unit, and have incidents reduced since the inspection?
This was an unannounced comprehensive inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 11 April 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Braeburn Lodge
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2015
Registered with the Care Quality Commission on 4 January 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
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