CQC report explained · a residential care home
What the CQC found at Burn Brae Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safeguarding systems, risk checks, sufficient staffing, safe recruitment, infection control measures and safe medicines management. Some paintwork was chipped and some handrails were not always impervious, making them harder to clean.
- Effective?
- Good
- This area was not inspected during this visit. CQC said no concerns had been identified and used the rating from the previous comprehensive inspection.
- Caring?
- Good
- This area was not inspected during this visit. CQC said no concerns had been identified and used the rating from the previous comprehensive inspection.
- Responsive?
- Good
- This area was not inspected during this visit. CQC said no concerns had been identified and used the rating from the previous comprehensive inspection.
- Well-led?
- Good
- Inspectors found approachable management, good communication with relatives, regular quality checks and effective working relationships with health and social care agencies.
What inspectors found, February 2021
Rated Good; inspectors found safe, caring and well-managed care, but some worn paintwork and hard-to-clean surfaces needed attention.
This was a focused inspection on 12 and 20 January 2021. It followed concerns about cleanliness and safe working arrangements during a recent COVID-19 outbreak. The inspector reviewed records, spoke with a person using the service, relatives, staff, managers and health professionals.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicines systems and suitable infection control arrangements. People and relatives said the home felt safe and that staff were caring and attentive.
This was not a full inspection of all five areas. Effective, Caring and Responsive were not inspected because no concerns had been identified in the information held by CQC. Their earlier ratings were used in the overall rating. The overall rating remained Good, as it was at the inspection published in October 2017.
Enough staff
Inspectors found there were enough staff to support people. Extra local authority and agency staff helped maintain safe staffing during the outbreak.
“There were sufficient staff to support people.” from the report
Safe medicines
Medicines records were clear and current. Staff had medicines training and competency checks, including recording whether as-needed medicines had worked.
“Medicines records were clear and up to date.” from the report
Infection control
The home followed national infection control guidance. Staff had access to PPE and one staff member led checks on hygiene practices.
“Staff were using personal protective equipment (such as aprons and gloves) effectively and safely.” from the report
Open management
Relatives said the provider and staff kept them informed during the pandemic and outbreak. Inspectors also found good links with health and social care agencies.
“Relatives said the provider and staff were "very good at keeping us informed" and up to date with the latest guidance.” from the report
Worn paintwork
minorSome parts of the home looked worn, with chipped paintwork. The provider began a refurbishment plan after the inspection.
“Some areas of the home were starting to look worn with many areas of chipped paintwork.” from the report
Surfaces harder to clean
minorSome contact points, including handrails, were not always made of surfaces that could be cleaned easily. This mattered during the inspection of infection control.
“Some contact points, such as handrails, were not always impervious so would be more difficult to keep clean.” from the report
- 01Has the refurbishment plan for the chipped paintwork been completed?
- 02Have the handrails and other contact points been changed or treated so they can be cleaned more easily?
- 03What staffing arrangements would be used if another infection outbreak meant home staff could not work?
- 04How will you keep relatives informed if there is another outbreak or change in visiting guidance?
- 05When was the last full inspection of Effective, Caring and Responsive, and what were the ratings for those areas?
This was a focused inspection of Safe and Well-led during the COVID-19 period; Effective, Caring and Responsive were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 17 February 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.
What inspectors found, October 2017
Rated Good; inspectors found safe, kind and personalised care, with some records and staffing processes needing improvement.
The inspection took place on 18 and 21 September 2017. It was unannounced on the first day and announced on the second. Inspectors spoke with people living there, relatives, staff and healthcare professionals. They observed care, meals and activities, and checked care, medicines, staff and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and well cared for. Inspectors saw kind staff, personalised care, suitable activities and good access to healthcare.
There were some shortfalls. The medicines trolley was sometimes left unlocked. Some complaints were not recorded, staff meetings were not regular, and some supervision, appraisal and care records needed more detail. The provider agreed to address these points.
The previous inspection found breaches about staffing and good governance. Inspectors found these areas had improved and the provider now met those regulations.
People felt safe
People and relatives said they felt safe. Inspectors also saw safe movement and appropriate moving and handling support.
“People told us they felt safe living at the service and relatives confirmed this.” from the report
Kind and respectful care
Staff treated people as individuals and maintained their dignity, privacy and independence. Relatives and people spoke positively about the care.
“Staff displayed positive and caring attitudes and interacted well with people.” from the report
Personalised care plans
Care records included people's preferences, health needs and personal interests. Plans were reviewed and shared with families and healthcare professionals.
“Care records were detailed and informative and person centred.” from the report
Improved management checks
The home had improved its quality monitoring since the previous inspection. Audits covered areas such as medicines, infection control, safety and falls.
“Audits were routinely carried out on the safety of the building, infection control and medicine management for example.” from the report
Medicines trolley security
needs fixingInspectors saw that the medicines trolley was not always locked while medicines were being given. The manager agreed this should be corrected immediately.
“Although we noted that the medicines trolley was not always locked while not in use.” from the report
Minor complaints not recorded
needs fixingThe home investigated recorded complaints, but not every verbal or minor concern was recorded. The manager said a system would be put in place to capture these.
“However, we noted that not all minor concerns had been recorded as one relative told us of an issue which had been dealt with, but we found this not recorded on any documentation.” from the report
Staff meetings were not regular
needs fixingStaff meetings had not taken place as often as inspectors expected. The provider was asked to hold regular meetings so staff stayed up to date.
“Regular staff meetings were not held as often as they should have been to ensure that staff were kept abreast of any pertinent issues arising.” from the report
Some records needed more detail
minorSupervision and appraisal records did not always contain enough detail about objectives and development. Some care records were also not fully updated each month.
“Staff appraisals had not fully detailed objectives, goals or the development plans for each staff member.” from the report
- 01How do you make sure the medicines trolley is locked whenever it is not in use?
- 02How are verbal and minor complaints recorded, investigated and followed up?
- 03How often are staff meetings now held, and how are actions shared with staff?
- 04Do supervision and appraisal records now include clear objectives, goals and development plans?
- 05How do you make sure care records and fluid totals are updated fully and on time?
This was an inspection of the overall service and all five CQC questions, with observations, discussions and record checks; it took place over two days and was unannounced on the first day. This explanation was written from the published report of 18 October 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 Burn Brae Lodge
3 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- February 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 2010.
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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