CQC report explained · a nursing home
What the CQC found at Braeside Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely, including missing guidance, incomplete administration records and unsafe storage. Staffing, recruitment, safeguarding, general risk management and infection control were stronger.
- Effective?
- Requires improvement
- The home assessed people's needs and supported nutrition and access to healthcare. However, it could not provide assurance that Deprivation of Liberty Safeguards conditions were understood, monitored or met.
- Caring?
- Good
- This key question was not inspected in this focused inspection. Inspectors observed staff who were patient, caring and responsive, and people spoke positively about their care.
- Responsive?
- Good
- This key question was not inspected in this focused inspection. Inspectors said staff knew people well and that people could raise concerns and were listened to.
- Well-led?
- Requires improvement
- The provider's audits and governance systems had not identified important problems with medicines, consent records and repairs. New management and oversight systems were being introduced but needed further development.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found kind and responsive care, but medicines, consent records and oversight were not reliable enough.
This was an unannounced focused inspection on 1 and 6 June 2023. Inspectors looked at Safe, Effective and Well-led after concerns about medicines, nursing care, recruitment, health and safety, and governance. They spoke with people, relatives and staff, observed care, and checked records and the building.
The home had enough staff, safe recruitment checks, and systems to protect people from abuse and infection. Risks were generally managed well. People said they were happy with their care, liked the food, and found staff caring, patient and responsive.
However, medicines were not always managed safely. Records and staff knowledge about some Deprivation of Liberty Safeguards were incomplete. Quality checks had failed to find these problems, and some repairs and fire drills had been delayed. The overall rating changed from Good at the previous inspection to Requires Improvement.
Enough staff
Inspectors found sufficient staff to meet people's needs. Call bells were answered promptly and people said staff came quickly when needed.
“There were sufficient staff deployed to meet people's needs.” from the report
Kind, responsive staff
Staff were observed to be patient, caring and responsive. People said staff were helpful and that they could raise concerns.
“Throughout the inspection staff were observed to be patient, caring and responsive.” from the report
Food and nutrition
People's nutritional needs were being met, with drinks available and staff aware of people's food preferences and specific needs.
“People's nutritional needs were being met. We saw drinks were readily available and people who stayed in their bedrooms were also provided with regular drinks.” from the report
Improving management
People and staff were positive about recent management changes. Communication with managers and the provider had improved, and managers were described as open and willing to improve.
“Everyone was very positive about recent changes in management and provider oversight.” from the report
Medicines safety
seriousSome medicines lacked clear instructions, records were incomplete, and insulin was stored outside the recommended temperature. These failures increased the risk of harm.
“Medicines were not always managed safely. People did not always have written guidance in place for staff to follow” from the report
Consent records
seriousStaff did not know which people had Deprivation of Liberty Safeguards or what conditions applied to them. The home could not show that required monitoring had taken place.
“Staff spoken with were not aware who was on DoLS, they did not know about any of the conditions that were in place.” from the report
Quality oversight
seriousAudits had not identified the medicines and consent problems found by inspectors. Some repairs had also not been reported promptly, and new governance systems were not yet fully embedded.
“The range of quality monitoring and audits in place did not identify the issues we found at inspection.” from the report
Building and fire arrangements
needs fixingSome parts of the building needed updating, there had been delays with repairs, and there had been too few fire drills. Improvement plans were in place.
“There had been a lack of fire drills.” from the report
- 01How are 'when required' medicines and medicines with a choice of dose now recorded and checked?
- 02How do staff know which residents have Deprivation of Liberty Safeguards and what conditions must be monitored?
- 03What evidence can you show that the three breached regulations have been addressed?
- 04Which repairs and building updates from the improvement plan have been completed, and what remains outstanding?
- 05Are fire drills now taking place monthly, and when was the most recent drill?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected, and the report says ratings for uninspected questions carried over from the last inspection. This explanation was written from the published report of 14 July 2023 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, February 2022
Braeside Care Home was inspected but not rated; inspectors found strong infection control during the COVID-19 review.
Inspectors visited on 20 January 2022. This was an announced, targeted inspection focused on infection prevention and control, including how the home was managing COVID-19-related staffing pressures.
They found staff had PPE training and were wearing PPE correctly. There were sufficient PPE supplies, regular testing, COVID-19 vaccination checks, visitor controls and arrangements to support visits.
The home was clean and uncluttered. Inspectors found cleaning schedules, audits and plans for managing infection outbreaks. The service was inspected but not rated, so this report does not provide a full rating of the home.
PPE and testing
Staff had been trained to use PPE and were observed using it properly. The home had ample supplies, and people and staff were tested regularly for COVID-19.
“Staff had received training in the use of Personal Protective Equipment (PPE), we observed staff wearing PPE as required.” from the report
Clean environment
Inspectors found the home clean and uncluttered. Cleaning schedules and checks were being used to monitor infection control.
“The home was very clean and uncluttered. Cleaning schedules were in place and there was a range of auditing and monitoring in place” from the report
Managing outbreaks
The home had policies, risk assessments and contact with local authority and public health teams to help manage infection outbreaks.
“The systems in place ensured any infection outbreaks could be effectively managed.” from the report
Supporting visits
Visitors were tested and required to wear PPE in line with government guidance. The manager was supporting visits under the guidance in force at the time.
“Visitors were required to undertake COVID-19 testing and wear PPE in line with current government guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01How are staffing pressures affecting people's care and daily routines now?
- 02How do you check that staff and visiting professionals meet the COVID-19 vaccination requirements or have an exemption?
- 03What are the current arrangements for visitors, including testing and PPE?
- 04How often are cleaning and infection-control checks carried out, and what happens when a check identifies a problem?
- 05What is the home's current plan if there is an infection outbreak?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 5 February 2022 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 Braeside Care Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 January 2011.
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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