We carried out a review of the data available to us about Staveley Birkleas Nursing Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Staveley Birkleas Nursing Home, you can give feedback on this service.
We undertook an unannounced comprehensive inspection of Staveley Birkleas on 22 January 2019.
At the last inspection in May 2018 we found the provider was in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities 2014) Regulations. This was in relation to 'Safe Care and Treatment' and 'Good Governance'. Following the inspection, the provider sent us an action plan stating how they would improve the service. At this inspection we found improvements had been made and the service was no longer in breach of regulation.
A registered manager was not in place. A manager had been recruited who was going through the CQC registered managers' assessment process. 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.
At the last inspection we rated the safe domain as inadequate. At this inspection we found the safety of the service had improved. However, we would need evidence that this could be sustained over time before we were fully assured the service was consistently safe.
People said they felt safe using the service. Overall, risks to people’s health and safety were assessed and mitigated and clear care plans were in place to guide staff. Safety incidents and safeguarding matters were appropriately managed and the service used any incidents to help improve the service. The premises were safely managed and were adapted to the needs of the people who used the service.
Medicines were managed in a safe manner although the service needed to ensure the recording of topical medicines such as creams was recorded in a consistent manner.
There were enough staff deployed to ensure people received prompt care and support including the provision of one to one hours. Staff were recruited safely to help ensure they were of suitable character to work with vulnerable people, with people who used the service involved in this.
Staff received a range of training which was relevant to their role. This was sourced through a variety of means including through developing relationships with local healthcare professionals. Staff said they felt well supported.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The registered provider’s policies and systems supported this practice.
People had access to a suitable range of food and drink and their nutritional needs were monitored appropriately by the service.
People’s healthcare needs were assessed and the service worked with a range of professionals to help meet those needs. People had clear and detailed care plans in place which were subject to review. People felt involved in decision making relating to their care.
People were cared for by staff who displayed kindness and compassion and treated people with dignity and respect. People’s feedback about staff was very positive.
People’s independence was promoted through care planning, and the provision of activities, exercise and physiotherapy.
People had access to a broad range of activities. The service had developed strong links with the local community and this combined with leisure facilities owned by the provider ensured plenty of opportunities were available to people.
People’s complaints were listened to and used to make improvements to the service. People provided very good feedback about the overall quality of the service and said it was well led. The service had a clear set of values centred around providing high quality person centred care. Staff understood these values and were true to them. Staff said that morale was good and that the service had improved over recent months.
Good governance systems were in place to assess, monitor and improve the service. Systems put in place by the new manager had led to an improvement to the overall quality of the service.
We undertook an unannounced focused inspection of Staveley Birkleas on 24 May 2018. This inspection was conducted following information of concern which we received which included a number of safeguarding concerns about the service. The primary aim of the inspection was to check the safety of the service and the ongoing risk of harm to people. The team inspected the service against two of the five questions we ask about services; ‘Is the service Safe?’ and ‘Is the service Well Led?’
At the last comprehensive inspection in January 2018 we found the provider was in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities 2014) Regulations. This was in relation to ‘Safe Care and Treatment’ and ‘Good Governance’. Following the inspection, the provider sent us an action plan stating it would be fully compliant with the regulations by 1 June 2018. We undertook this inspection before this date, because we needed to promptly check the safety of the service. At this inspection we found the service was still in breach of these regulations. We found a number of issues and lack of progress in becoming compliant with the regulation. Due to the number of issues we found we rated the ‘Is the service Safe?’ domain as ‘Inadequate’. We saw some improvements had been made to the management structure within the home which gave us some assurance that this would lead to improvements to the safety of the service in the future. Overall, we kept the service’s rating at ‘Requires Improvement’.
A registered manager was in place. 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.
Risks to people’s health and safety were not properly assessed. Risk assessment and care plan documents were not always present or up-to-date. Incident management processes needed improving. Incident descriptions and action taken was not always recorded which did not provide us with assurance that action had been taken to mitigate risks.
There was a lack of protocols and information available for staff to help ensure ‘as required’ medicines were given consistently and appropriately.
Nurse staffing levels had been improved since our last inspection. However, some people were not consistently receiving their contracted hours of one to one support. These people needed these for companionship, activity and to reduce distress.
The service had introduced clinical leads into the home to help improve nursing practice and assist with monitoring and checking how the service was operating. However, we identified continued risks to people’s safety which should have been prevented from happening through the operation of robust systems of governance and audit.
We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations. You can see what action we asked the provider to take at the back of the full version of this report.
The inspection was undertaken on 3 and 10 January 2018 and was unannounced. At the last inspection in September 2016 we rated the service ‘Good’ overall and ‘Requires Improvement’ in the ‘Is this Service Well Led?’ domain. We identified a breach of regulation relating to ‘Good Governance’ as care records did not always demonstrate people’s needs were met. At this inspection we also found issues with care and support records which impacted on the service’s ability to evidence appropriate care.
A registered manager was not in place, although a manager was in post who told us it was their intention to apply to be the registered manager of the service. 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.
People’s feedback about the home was positive. They said they felt safe and secure living at Staveley Birkleas and were satisfied with the care provided. We found the home adhered to some good areas of practice. For example, there was a person centred culture with people able to pursue their preferred routines, interests and aspirations. Staff genuinely cared for people and we saw evidence the service had gone the extra mile to ensure people were provided with social opportunities, activities and bespoke and individualised equipment. However improvements were needed to care plan documentation, in order to evidence that appropriate care was consistently provided. There was a lack of oversight, review and audit of some areas of care and a lack of nursing leadership within the home. Because of these issues and despite the good areas of practice we identified, this meant we were unable to rate the service better than ‘requires improvement.’
People said they felt safe and secure living in the home. We saw safeguarding procedures were in place and had been followed to help keep people safe. Following incidents, investigations were undertaken and learning took place following each incident to help ensure continuous improvement.
Most medicines were managed safely and given as prescribed. However records were not always kept for the application of topical medicines such as creams.
Overall staffing levels were appropriate and enabled people to experience prompt care and support. However nursing staffing levels were not always maintained at the same level and some staff raised concerns about this. We made a recommendation in relation to nurse staffing levels.
Most risks to people’s health and safety were appropriate assessed and mitigated, however nutritional risks were not always properly monitored or reviewed. Where people’s nutritious input was being monitored, charts did not always evidence they had received a suitable diet.
Staff received a range of training tailored to their individual requirements. Care staff received supervision, however supervision for nursing staff required bringing up-to-date. We made a recommendation in relation to carrying out nursing supervision.
The service was compliant with the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). We saw people were given choices and control over their lives and consent was sought before care and treatment interventions.
The service worked in partnership with other agencies and health professionals to help ensure people’s needs were met. Technology was utilised to make these relationships effective and timely.
People all said staff were kind and caring and treated them well. Good positive relationships had developed between people and staff. People’s independence was encouraged and the service had a high regard for people’s privacy and dignity.
People living in the home were not discriminated against and the service took steps to ensure individualised equipment was provided and adjustments were made to meet people’s diverse needs and requirements.
People’s care needs were assessed and in the most part appropriate plans of care put in place which met their individual needs and requirements. People’s preferences were reflected in care planning. People said care needs were met by the service.
People had access to an excellent range of activities and social opportunities. The service had developed strong links with the local community which benefited people who used the service.
People’s complaints were recorded, investigated and acted on. People said they knew how to complain and felt comfortable raising issues with staff and management.
We found a good culture within the home with staff committed to ensuring people received person centred care. Feedback from people, relatives and staff about the home was very positive.
The home had achieved accreditation with external organisations such as the Investors in People award as a method to help ensure high quality and continuous improvement.
However systems to assess, monitor and improve the service were in place but some of these needed to be more robust. Greater nursing oversight was required of daily charts and care and support plans. Care records showed a lack of nursing input and nursing staff said they did not always have the time to review care plans and charts. Some audits such as care plan audits were not undertaken at the frequency specified by the provider. This was also the case at the last inspection.
People were involved in the running of the home through various mechanisms including the resident and relative meeting. Some people were also involved in the recruitment of staff. People’s views and opinions were valued and used to make improvements to the service.
We identified two breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the full version of the report.
We inspected the service on 8 September 2016 and it was unannounced. On the day of the inspection 55 people were living at the home.
A registered manager was in place. 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.’
People and relatives we spoke with told us the service delivered good quality care and they did not raise any significant concerns with us. People said they felt safe and secure in the home and there were plenty of activities. They said care and support provided was appropriate and met their individual needs. However some people raised concerns that the quality of the service was not always maintained at weekends.
The risks to people’s health and safety were assessed and clear plans of care put in place which were well understood by staff. People were appropriately involved in the risk assessment process. Staff understood how to identify and act on any safeguarding concerns.
Overall, we concluded medicines were safely managed. People received their medicines as prescribed and medicines were stored securely.
Overall, we concluded there were sufficient staff to deliver timely care to people. People provided mixed feedback about staffing levels with some people and staff saying staffing levels were stretched at the weekends. Safe recruitment procedures were in place.
The premises was safely managed. There was appropriate communal areas for people to spend time and the required maintenance and safety checks took place on the building.
Staff had access to a range of training which was provided at periodic intervals. Staff said training was appropriate and gave them the skills to meet people’s individual needs.
People told us the food was good and that they had sufficient choice. We found mealtimes to be a pleasant experience. Nutritional needs were assessed and action taken to address any nutritional risks.
The service was acting within the legal framework of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). People reported choice and control over their daily lives.
People and relatives spoke highly of staff and said they were treated with dignity and respect and their privacy was respected. This was confirmed by our observations of care and support.
Care records provided information of people’s life and personal histories had been obtained to help staff better understand people. Staff we spoke with had a good understanding of the people they were caring for.
People’s needs were assessed and clear and person centred plans of care put in place. People told us the service delivered appropriate care that met their needs.
A programme of activities was in place, provided by an activities co-ordinator. People spoke positively about the activities on offer at the home.
A system was in place to record, investigate and respond to any complaints. People said they were very satisfied with the service, but were confident action would be taken to address any concerns.
People were listened to and their opinions used to make positive changes to the service.
Systems to assess, monitor and improve the service were not sufficiently robust. Some audits were carried out, but not at regular frequencies and the actions arising from audits were not always signed off.
Although we established appropriate care was delivered by the service, care records did not always contain accurate or complete information.
We found one breach of the Health and Social Care Act (2008) Regulated Activities 2014 Regulations. You can see what action we asked the provider to take at the back of this report.
' Is the service safe?
' Is the service effective?
' Is the service caring?
' Is the service responsive?
' Is the service well led?
This is a summary of what we found. The summary describes the records we looked at, our observations and what people who used the service, visitors and staff told us.
Is the service safe?
The six people we spoke with who lived at the home raised no concerns about their safety and said if they had concerns they would discuss them with the manager. We spoke with two visitors, they told us they were pleased with the standard of care and facilities provided by the service.
Each person's care file had risk assessments which covered areas of potential risk. When people were identified as being at risk, their plans showed the actions required to manage these risks.
There were enough skilled and experienced staff to ensure people received a consistent and safe level of support.
The care records reviewed were relevant, complete and up to date; they were also stored securely to ensure confidentiality. We saw appropriate records were maintained in relation to the management of the service. All records were located promptly when requested.
Is the service effective?
People told us they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well.
We saw evidence the home had a good working relationship with other healthcare professionals and followed their guidance and advice. The input of other healthcare professionals involved in people's care and treatment was clearly recorded within their care plan.
Is the service caring?
We found the care staff we spoke with demonstrated a good knowledge of people's needs and were able to explain how individuals preferred their care and support to be delivered. We found the atmosphere within the home was calm and relaxed and we saw staff approached individual people in a way which showed they knew the person well and knew how best to assist them.
Our observations of the care provided, discussions with people and records we looked at told us that individual wishes for care and support were taken into account and respected.
Is the service responsive?
Care records were reviewed and any changes made either when people's needs changed or as part of the monthly review process. We saw evidence of this within the care records we reviewed.
We found people knew how to make a complaint if they were unhappy. The provider had an effective policy in place for dealing with complaints. We saw evidence the service took complaints seriously and investigated and responded to them in line with the provider's complaints procedure.
Is the service well-led?
We saw there was a quality assurance monitoring system in place that was designed to continually monitor and identify shortfalls in the service. The people we spoke with and staff told us the home was well led. They said the management team were approachable and dealt with any issues or concerns quickly.
The people who used the service and their relative told us they were looked after well and felt safe with the care and treatment provided. Their comments included: "I like it here", 'They are all nice' and 'I love it here'.
We found that the service had systems in place to ensure consent was gained before staff proceeded with personal care.
We spent time observing the lounges and dining area during the day of our inspection. We looked at how people spent their time and how staff interacted with people. The interactions we saw between staff and people who used the service and visitors were respectful. We saw some people engaged in activities with members of staff such as watching TV.
The provider had suitable arrangements in place to make sure people were provided with a choice of suitable and nutritious food and drink.
Staveley Birkleas Nursing Home obtained five stars for food hygiene from the local authority inspection team for both kitchens in October 2013.
As part of our inspection we asked the provider to explain the assurance system they used to monitor all aspects of the service. The provider had a system in place which gathered and recorded information about the quality and safety of care the service provided.
People we spoke with told us staff were kind to them. One person said, 'nothing is too much trouble".
We were able to speak with two relatives during our visit who told us that they could come and visit their relative at any time; one commented "I come and go as I please."
You can see our judgements on the front page of this report.