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Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 June 2017

Birkdale Park is registered to provided accommodation, nursing and personal care for up to 36 adults. The home admits older people with general nursing care needs. It is a large detached house on a main road leading to Southport town centre. There were 29 people accommodated at the time of the inspection. The home was last inspected in December 2014 and was rated ‘Good’ at that time.

This inspection was carried out over two days on 20 and 24 April 2017 and was unannounced.

At the time of the inspection there was a manager in post but they were not yet registered with us (the Care Quality Commission). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The manager had applied to be registered.

We found some anomalies with the way some medicines were being recorded and monitored. This meant there was a risk these medicines were not being administered consistently. We found the checking and auditing systems of medicines needed some improving to ensure all areas of medication management were being identified and routinely checked.

The manager and senior managers for the provider were able to evidence a range of quality assurance processes and audits carried out at the home. We found some supporting management audits needed to be further developed with respect to medicines. Some clinical records regarding health were not always clear. The manager was aware of their responsibility to notify us [The CQC] of any notifiable incidents in the home although criteria for submitting these needed reviewing.

You can see what action we told the provider to take at the back of the full version of this report.

We found some anomalies with the care of two people in the home and found that monitoring of care could improve and be more consistent. We made a recommendation regarding this.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were generally followed in that an assessment of the person’s mental capacity was made but this was not always consistent.

We found the home generally supported people to provide effective outcomes for their health and wellbeing. We saw there was referral and liaison with health care professionals when needed to support people.

We found there were sufficient staff on duty to meet people’s care needs. Staff said they were supported through induction, appraisal and the home’s training programme.

We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We saw required checks had been made to help ensure staff employed were ‘fit’ to work with vulnerable people.

People we spoke with said they were happy living at Birkdale Park. Staff mostly interacted well with people living at the home and they showed a caring nature with appropriate interventions to support people.

People told us their privacy was respected and staff were careful to ensure people’s dignity was maintained.

Care was organised so any risks were assessed and plans put in place to maximise people’s independence and helped ensure people’s safety.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. Training records confirmed staff had undertaken safeguarding training in-house. All of the staff we spoke with were clear about the need to report any concerns they had.

Arrangements were in place for checking the environment to ensure it was safe. For example, health and safety checks were completed on a regular basis so hazards could be identified. Planned development / maintenance was assessed and planned well so that people were living in a comfortable and safe environment.

The home was clean and we there were systems in place to manage the control of infection.

When necessary, referrals had been made to support people on a Deprivation of Liberty [DoLS] authorisation. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. The applications were being monitored by the manager of the home.

We saw people’s dietary needs were managed with reference to individual preferences and choice. Lunch time was seen to be a relaxed and sociable occasion.

People we spoke with and their relatives felt staff had the skills and approach needed to ensure people were receiving the right care.

People felt involved in their care and there was evidence in the care files to show how people had been included in key decisions.

Social activities were organised in the home. People told us they could take part in social events which were held.

We saw a complaints procedure was in place and people, including relatives, we spoke with were aware of how they could complain. We saw there were records of complaints made and there had been a response to these.

Inspection areas

Safe

Requires improvement

Updated 2 June 2017

The service was not always safe.

We found some anomalies with the recording of some medicines which meant it was not clear if the medicines had been given as prescribed.

Staff had been appropriately checked when they were recruited to ensure they were suitable to work with vulnerable adults.

We found there were protocols in place to protect people from abuse or mistreatment and staff were aware of these.

There were enough staff on duty at all times to help ensure people’s care needs were consistently met.

There was good monitoring of the environment to ensure it was safe and well maintained. We found that people were protected because any environmental hazards were routinely monitored.

The home was clean and we there were systems in place to manage the control of infection.

Effective

Requires improvement

Updated 2 June 2017

The service was not always effective.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were not always followed in that an assessment of the person’s mental capacity was not consistent.

The service supported people to provide effective access to health care outcomes.

Staff told us they were supported through induction, appraisal and the home’s training programme.

We saw people’s dietary needs were managed with reference to individual preferences and choice.

Caring

Good

Updated 2 June 2017

The service was caring.

Staff interactions were observed to be supportive and positive. Staff communicated well with people.

People told us their privacy was respected and staff were careful to ensure people’s dignity was maintained.

People told us they felt involved in their care and could have some input into the running of the home.

Responsive

Requires improvement

Updated 2 June 2017

The service was responsive.

We found some anomalies with the care of two people we reviewed in the home and found that monitoring of care could be more consistent.

Most peoples care plans were being reviewed and people’s care evidenced an individual approach.

There were social activities planned and agreed for people living in the home.

A process for managing complaints was in place and people we spoke with and relatives knew how to complain. Complaints made had been addressed.

Well-led

Requires improvement

Updated 2 June 2017

The service was not wholly well led.

The manager and representative for the provider were able to evidence a range of quality assurance processes and audits carried out at the home. With respect to medicines and consistency in assessing capacity for people, the audits had not picked up on the shortfalls we identified at the inspection.

Some clinical records regarding peoples on-going monitoring were not always clear.

Criteria for submitting statutory notifications to the Commission needed reviewing.

At the time of the inspection there was a manager in post but they were not yet registered with us (the Care Quality Commission).