Birkdale Village Care Home

We found the following examples of good practice.

The home was visibly clean and hygienic with regular cleaning schedules in place.

There was an up to date infection prevention and control policy.

There was a good supply of PPE available throughout the home. Staff followed guidance around the use of PPE.

The manager completed spot checks to make sure staff were following guidance around hand hygiene and use of PPE.

Staff and people living at the home tested regularly for COVID-19 in line with guidance.

The manager made sure that visits from friends and relatives were facilitated safely.

Birkdale Village Care Home is a residential home providing personal care for people aged 60 and over. There are 19 rooms available with 16 residents living there currently. Birkdale Village is one building, across three floors. All floors are accessible via a lift.

People’s experience of using this service and what we found

People appeared well cared for and looked after. There was a caring and positive culture amongst staff at the service. However, the systems and processes underpinning people’s care were not always safe and robust.

Although we found no evidence that people had been harmed as a result, we identified several areas that put people’s health and safety at potential risk.

The provider did not have an effective system in place to safely manage the administration of people’s medicines. The provider did not have an adequate system in place to learn lessons if mistakes were made. We have made a recommendation about updating some risk assessments, as well as incident recording and audits.

There was a ‘family’ type feel and many of the staff had worked at the service for several years, meaning they knew the people that lived there well. However, although we found no evidence of safeguarding concerns during our inspection, there was a lack of formal systems and processes in place to protect people from the risk of abuse. We have made a recommendation regarding safeguarding processes.

Governance systems were not always effective and needed to be updated, to ensure opportunities were not missed to improve the service. However, the provider did respond positively and effectively to feedback from other professionals, to make improvements to people’s care.

People were protected from the risk of spread of infection especially around COVID-19. At the time of inspection there had been no recorded cases in the service throughout the pandemic. People and relatives said they felt safe and there were enough staff to safely meet their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: The last rating for this service was good (July 2019).

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We received concerns in relation to infection and prevention control, and the governance of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider has taken some actions to mitigate the risks.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Birkdale Village Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to the management of medicines, staff recruitment and monitoring the quality and safety of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Shandon House is a residential care home providing personal and nursing care to 14 people aged 65 and over at the time of the inspection. The service can support up to 20 people in one adapted building over different floors.

People’s experience of using this service and what we found

We read in one relative’s feedback, “The residents and staff are like a family and family visitors seem to be treated just the same.” This was echoed by everyone we spoke with during the inspection. Visiting health professionals told us how much they enjoyed coming to Shandon House. They praised the positive, effective relationship they had with the service to look after people’s health and wellbeing.

We found issues with regards to health and safety checks and medicines management that needed to be improved to protect people robustly. We made recommendations regarding these matters. However, people told us they felt safe living at Shandon House. People said the staff treated them with respect and kindness and we observed this. We saw that people had developed friendships with others living at the home and cared for each other.

The provider had recognised that the service needed refurbishment and redecorations were ongoing. A variety of activities were still on offer, including regular visits by entertainers, although there had been fewer trips out. People were offered regular drinks throughout the day and a variety of food to choose from. There were enough staff to meet people’s needs and staff knew people well. The registered manager was developing person-centred plans and how they involved people and their families. Staff felt supported and involved in the development and delivery of the service. The well-respected registered manager led a service culture that promoted equality and diversity.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 5 January 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Shandon House is a care home providing accommodation and personal care for up to 20 older people. It is a converted house with gardens and seating areas at the side and front of the building. There is a ramp at the main entrance to assist people with limited mobility. Bedrooms, bathrooms and lounges are situated on the ground and upper floors. Some bedrooms have ensuite facilities. There were 17 people living in the home at the time of our inspection.

There was a registered manager in post. 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.

Medicines were managed safely in the home.

Risk assessments had been undertaken to support people safely and in accordance with their individual needs.

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.

Safety checks of the environment and equipment were completed regularly.

There were enough staff on duty to provide care and support to people living in the home.

The provider had robust recruitment procedures in place to ensure staff were suitable to work with vulnerable adults.

Staff worked in partnership with health and social care professionals to make sure people received the care and support they needed.

Staff were trained to ensure that they had the appropriate skills and knowledge to meet people’s needs. They were well supported by the registered manager.

Staff sought the consent of people before providing care and support. The home followed the principles of the Mental Capacity Act (2005) for people who lacked mental capacity to make their own decisions.

People told us they liked the food and were able to choose what they wanted to eat.

People told us the staff had a good understanding of their care needs and people’s individual needs and preferences were respected by staff.

People at the home told us they were listened to and their views were taken into account when deciding how to spend their day.

Care plans provided information to inform staff about people's support needs, routines and preferences.

People told us staff were kind, polite and maintained their privacy and dignity. We observed positive interaction between the staff and people they supported.

A programme of activities was available for people living at the home to participate in.

A process for managing complaints was in place. People we spoke with knew how to raise a concern or make a complaint.

Feedback we received from people, relatives and staff was complimentary regarding the registered manager’s leadership and management of the home.

Staff told us there was an open and transparent culture in the home.

Systems and processes were in place to assess, monitor and improve the safety and quality of the service.

People living in the home and relatives told us they were able to share their views and were able to provide feedback about the service.

Those we spoke with said the staff knew what support they required and did everything that was needed for them. One person told us, 'The care is very good. There's enough staff around when I need them.' Another person said, 'I've seen my GP a few times. The staff arrange things for me.'

People were very relaxed around staff and said they were listened to, so any concerns could be addressed. People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening

We spoke with staff. They told us they felt supported in their job. They told us there was good communication between different levels of staff. They felt there was always enough staff on duty to carry out the care needed. We asked people who used the service about the skills of the support workers. They told us the staff worked very hard and knew how to do their job. They felt staff were competent.

We looked at the system to manage complaints in the home. We found the complaints procedure was available to people. There were no complaints recorded for the service since our last inspection.

We looked at various records. These included care records and staff records. We found the records were up to date and held securely.

told us they were happy with the way staff supported them and the way they were cared for.

Those we spoke with said the staff knew what support they required and did everything that was needed for them. One person told us, 'It's OK here. The care is very good and that's the main thing.'

We spoke with three care staff. They told us they had received relevant training and they felt supported in their job and received supervision from their manager. We asked people who used the service about the skills of the care staff. They told us the staff worked very hard and knew how to do their job. They said staff were competent.

We spoke to people about the service they received with regards to their involvement in monitoring the quality of the service. They told us they had attended a recent meeting so that their views could be known. They said they were able to contact the manager if they ever had a problem with the service.

We looked at how medicines were managed and found that some improvements were needed to ensure these were monitored effectively.