CQC report explained · a nursing home
What the CQC found at Briardene Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, medicines, staffing, safeguarding and infection control were managed appropriately, although some as-required medicine protocols were less detailed than others.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Audits and action plans were used to monitor quality and safety. The manager was described as approachable, but written records about duty of candour were not always kept.
What inspectors found, May 2022
Rated Good; inspectors found safe care and improved management, with record-keeping about openness needing attention.
This was an unannounced, focused inspection on 10 May 2022. One inspector spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found that people felt safe, staff understood safeguarding, risks were assessed, medicines were managed safely and infection control measures were in place.
The home had improved since its previous inspection, which was rated Requires Improvement and found breaches of regulations. The previous breaches had been addressed, so the home was no longer in breach.
Inspectors recommended improving written records about duty of candour. This concerns recording actions and apologies after notifiable safety incidents. The other three areas were not inspected during this visit, so their previous ratings were used for the overall rating.
People felt safe
People and relatives told inspectors they felt safe. Staff knew how to recognise and report possible abuse.
“People and their relatives told us they felt safe with the staff.” from the report
Improved risk management
The home had assessed risks such as falls, diabetes and epilepsy. Accidents and incidents were recorded and reviewed for learning.
“Risks were assessed, and plans were in place to minimise and manage those risks.” from the report
Infection control
Inspectors were assured that the home had appropriate measures to prevent and manage infections, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Better quality oversight
The home had introduced audits and other checks to monitor safety and quality. Inspectors found enough improvement to remove the previous governance breach.
“A range of audits were completed which monitored the quality and safety of the service.” from the report
Duty of candour records
minorThe manager understood the responsibility to be open and honest after notifiable safety incidents. However, written records of actions and apologies were not kept, and inspectors made a recommendation.
“Notifiable safety incidents were recognised and responded to however written records of action taken and apologies offered were not kept.” from the report
Some medicine protocols lacked detail
minorProtocols existed for medicines given when needed, but some did not explain in enough detail how a person might show pain or anxiety.
“Protocols were in place for 'as required' medicines however some were more detailed than others in relation to how people presented if they were in pain or anxious.” from the report
- 01What changes have you made to record actions and apologies after notifiable safety incidents?
- 02How do you make sure as-required medicines are given appropriately when someone cannot clearly explain pain or anxiety?
- 03What were the previous breaches relating to safe care and governance, and how do you check that the improvements have lasted?
- 04When will resident and relative meetings be fully re-established, and how will feedback be acted on?
- 05What are the current ratings and findings for Effective, Caring and Responsive care, which were not covered by this inspection?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection and were used to calculate the overall rating. This explanation was written from the published report of 26 May 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.
What inspectors found, May 2021
Requires Improvement; inspectors found serious infection-control and monitoring failures, although staff were caring and there were enough staff.
This was an unannounced inspection on 11 and 12 February 2021. It followed concerns about safeguarding and staff conduct. Inspectors spoke with people, relatives and staff, observed care, and reviewed care, medicines, recruitment and management records.
The home was not always safe. Staff did not consistently follow infection-control guidance, including rules about masks, gloves, aprons, cleaning and social distancing. Some risk assessments did not explain the possible impact of COVID-19, and records did not always show what action was taken after accidents.
The home was not always well led. Audits had not found or fixed the problems inspectors identified, and staff checks on infection-control practice were not being completed. The overall rating fell from Good at the previous inspection to Requires Improvement.
Inspectors found caring staff, enough staff to meet people's needs, safe medicines systems and safeguarding procedures. Caring was inspected but not rated during this visit.
Enough staff
Inspectors found enough staff were deployed to meet people's needs and respond in a timely way.
“There were enough staff deployed to meet the needs of people.” from the report
Safe medicines systems
Medicines records were accurate, and guidance was available for medicines prescribed only when needed.
“Medicine administration records were accurate and showed people had received their medicines as prescribed.” from the report
Caring and independence
Staff were described as kind and compassionate. They used prompts and encouragement to help people remain as independent as possible.
“Staff worked in ways to encourage people to be as independent as possible.” from the report
Safeguarding awareness
Staff understood their role in protecting people from abuse and said they would raise concerns.
“Staff understood their role in how to protect people and told us they would be confident to raise any concerns if they suspected any form of abuse.” from the report
Infection-control practice
seriousStaff did not consistently follow government guidance on PPE, gloves, aprons, cleaning and social distancing. This increased the risk of infection spreading.
“Staff did not follow government guidance for the wearing and removing of Personal Protective Equipment (PPE).” from the report
Risk records
seriousRisk assessments did not explain the possible impact of COVID-19 on people with underlying health conditions. Records about repeated falls did not show whether extra measures were needed.
“The providers failure to assess, monitor and mitigate all the risks people were exposed to contributed to a breach of Regulation 17” from the report
Weak quality monitoring
needs fixingAudits did not identify all the problems found during the inspection, and some issues identified by audits were not dealt with.
“A range of audits were completed at the service. However, they were not effective at robustly monitoring quality and had not identified the issues we found during this inspection.” from the report
Staff infection-control checks
needs fixingThe management team did not complete competency checks and assessments to monitor staff understanding and practice in infection control.
“Competency checks and assessments were not undertaken with staff to monitor their practice and understanding of IPC practices.” from the report
- 01What has changed since the inspection to make sure staff wear, remove and replace PPE correctly?
- 02How are cleaning of highly touched surfaces and communal resources now checked?
- 03How are COVID-19 risks and other individual risks recorded and reviewed?
- 04How do you make sure accidents, including repeated falls, lead to additional action where needed?
- 05What staff competency checks and audits are now in place, and how are problems followed up?
This began as a targeted inspection following specific concerns and was widened to a focused inspection of Safe and Well-led; Caring was inspected but not rated, and the other key questions were not covered. This explanation was written from the published report of 29 May 2021 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 Briardene Care Home
3 rated inspections over 2 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2021Requires improvementSafe: Requires improvementCaring: Inspected but not ratedWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- January 2020GoodSafe: GoodWell-led: Good
- January 2019
Registered with the Care Quality Commission on 8 January 2019.
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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