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Inspection carried out on 30 April 2018

During a routine inspection

Birkdale Park is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. 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 26 people accommodated at the time of the inspection. The home was last inspected in April 2017 and was rated ‘Requires Improvement’ at that time.

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; Safe, Effective, Responsive and Well-led to at least good.

This inspection was conducted on 30 April and 3 May 2018 and was unannounced on the first day.

A registered manager was in post, and the ratings from the previous inspection were displayed as required. 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 our last inspection in April 2017 we identified a breach of regulation because audit processes had failed to identify a number of concerns and omissions that were picked-up by the inspection team. Following the inspection the provider submitted an action that detailed how the necessary improvements would be made and sustained. At this inspection we found the audit processes at Birkdale Park were extensive and covered a wide range of safety and quality indicators. The provider had made and sustained the necessary improvements in accordance with their action plan and was no longer in breach of regulation regarding audits.

We saw evidence that managers at Birkdale Park used information from audits, accidents, incidents and feedback to learn and develop. There was evidence that the management team at Birkdale Park were making good use of external resources, guidance and partners to measure performance and drive quality improvements.

At our last inspection in April 2017 we identified a breach of regulation because records relating to the administration of medicines contained anomalies which meant it was not clear if the medicines had been given as prescribed. Following the inspection the provider submitted an action plan which detailed how the home would improve practice. As part of this inspection we checked to see if the necessary improvements had been made and sustained.

Medication was safely administered and the provider was no longer in breach of regulation regarding the safe administration of medicines. However, some records and systems were difficult to navigate and could be further improved. We made a recommendation regarding this.

People and their relatives told us they felt safe living at Birkdale Park. People were kept safe because staff had been trained in adult safeguarding and understood indicators of abuse and what action to take. Risk was fully considered as part of the assessment and care planning process. The care records that we saw showed that risk had been assessed and reviewed in relation to a number factors including; falls, skin integrity and weight-loss.

As part of the inspection we checked the operation of fire doors and found that some did not close fully. This meant that they may not have been effective in the event of a fire. We reported this to the registered manager who arranged for each door to be checked and adjusted as required before the end of the inspection.

Staff were recruited safely in accordance with requirements. Staff were deployed in sufficient numbers to keep people safe and meet their needs. However, people living at Birkdale Park and staff commented that the allocation of staff overnight meant that people were sometimes kept waiting for care.

Prior to the inspection we received information of concern which indicated that people were not given sufficient fluids to maintain a safe level of hydration. As part of the inspection we checked the availability of fluids and the monitoring of consumption. We found that the people had appropriate access to fluids and were supported to drink.

Staff had completed a programme of training in relevant subjects such as; food safety, health and safety, moving and handling and safeguarding. Staff told us that they felt well-supported by the provider. Staff were given regular formal supervision and could access additional support at any time.

The home operated in accordance with the principles of the Mental Capacity Act 2005 (MCA). Applications to deprive people of their liberty had been made appropriately and were subject to regular monitoring.

We saw evidence that people were supported to access healthcare in a timely manner as required. Documentation in care records showed that people had made use of GP’s, opticians and dieticians amongst others.

Parts of the building had been adapted to meet the additional needs of people. For example, a stair-lift and a passenger lift had been installed to help people move around the building and high-contrast paint schemes had been used on hand-rails to make them easier to see.

Prior to the inspection we received information of concern which indicated that staff did not always treat people with respect. As part of the inspection we spoke with people living at Birkdale Park, relatives, visitors and staff to gather their views. Each of the people that we spoke with was positive about their relationship with staff and the quality of care that they provided. Staff knew people well and interacted with them in a relaxed, caring and supportive manner. Staff took time to speak with people and offer information and re-assurance as required.

Staff were clear about their responsibility to protect people’s right to privacy and dignity in the provision of care. They explained how personal care was given in people’s bedrooms or in locked bathrooms. Each of the people that we spoke with confirmed that staff treated people with respect in the provision of personal care.

Following the last inspection in April 2017 we made a recommendation to improve practice in relation to the monitoring of people’s care. As part of this inspection we looked in detail at four care records. Each of the four records was sufficiently clear and well-detailed to instruct staff how to provide safe, effective care.

People’s need regarding equality and diversity were assessed and recorded. We saw and heard of examples relating to people’s culture, faith and sexuality. Staff were aware of people’s different needs and reflected them in the provision of care.

Birkdale Park employed an activities coordinator who engaged with individuals and groups. The home had a programme of activities and events including; seed planting, gentle exercise, hair day, scented activity and songs of the war. We spoke with the coordinator and observed them providing activities. It was clear that they knew people and their preferences well. The people that we saw were fully engaged and appeared to enjoy the activities available.

Birkdale Park increasingly provided end of life and palliative care to people. The registered manager recognised the additional requirements of this model of care and was in the process of sourcing specialist training for care and nursing staff.

Inspection carried out on 20 April 2017

During a routine inspection

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 carried out on 11 and 12 December 2014

During a routine inspection

Birkdale Park is registered to provided accommodation, nursing and personal care for up to 25 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.

This was an unannounced inspection which took place over two days on 11 and 12 December 2014. The inspection team consisted of an adult social care inspector and an ‘expert by experience’. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

The service had 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.

During our inspection we saw that staff and visitors were made aware of the need to ensure people’s safety. People who lived at Birkdale park and visitors commented that they always felt safe in the home environment as there was always staff available. People commented: “Yes, everybody cares for me.” “Yes, there are people around me.” “I don’t feel anything could happen here.” “They look after you.” “People are so friendly.”

People living at the home were ‘safe’ from abuse because the staff understood what abuse was and the action they should take to ensure actual or potential abuse was reported. Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults. People and their families told us there was sufficient numbers of staff on duty at all times.

We looked at how medicines where managed in the home. We found safe medicine practices which were monitored and reviewed. A visiting health care professional advised us that the home were particularly proactive at ensuring regular medication reviews took place.

We observed staff supporting people in a way that ensured their safety whilst maintaining their dignity and promoting their independence. The care records we looked at showed a range of risk assessments had been completed depending on people’s individual needs. For example, people had been appropriately assessed when they presented with a risk of developing a pressure sore and if they needed extra equipment to ensure their safety such as bedrails.

Health professionals who visited the home gave us feedback about the care. They described a proactive service which identified any issues regarding people’s health and ensured they received the right support and intervention.

We looked at the training and support in place for staff. We saw a copy of the induction for new staff and staff we spoke with confirmed they had up to date and on-going training. We spoke with a new member of staff who told us they felt well supported and comfortable in their role. Most of the training in the home is via on line training courses. Staff we spoke with appreciated this training although some commented that it did not always suit their learning style and they would prefer a more mixed approach to training. This was discussed with the manager as a developmental issue.

We looked to see if the service was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. People living at Birkdale park varied in their capacity to make decisions regarding their care. We saw examples where people had been supported and included to make key decisions regarding their care. Where people had lacked capacity to make decisions we saw decisions had been made in their ‘best interest’. We saw this followed good practice in line with the MCA Code of Practice.

We were told that the home does not currently support anybody who is on a deprivation of liberty authorisation [DoLS]. 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.

We discussed with staff and the people living at the home how meals were organised. People told us the meals were good and well presented. One person said, ‘’It’s very nice. If I didn’t like it they would get me something else. At teatime we get sandwiches and they know I prefer brown bread.’’ We saw that people who needed support to eat had sufficient staff time allocated and that staff took time to talk to and socialise with people.

We were told the staff were very caring and supportive. A person said, ‘’The staff are very friendly. The manager comes around and says goodnight to each resident.” The staff we spoke with had a good knowledge of people’s needs and were able to explain people’s individual routines. This was supported by the observations, interviews and records we saw on the inspection.

We looked at the care record files for seven people who lived at the home. We found that care plans and records were individualised to people’s preferences and reflected their identified needs. Some were very detailed and there was evidence that care plans had been discussed with people and also their relatives if needed. We could see from the care records that staff reviewed each person’s care on a regular basis.

We observed a complaints procedure was in place and most people, including relatives, we spoke with were aware of this procedure. We saw that any concerns or complaints made had been addressed and a response made.

We enquired about the quality assurance systems in place to monitor performance and to drive continuous improvement. The manager was able to evidence a series of quality assurance processes which provided feedback and monitoring so that the service could continue to develop.

Inspection carried out on 1 November 2013

During a routine inspection

We spoke with people about the service that they received. They told us they were happy with the way staff supported them and the care they carried out for them.

The people we spoke with said the staff knew what support they required and did everything that was needed for them. One person told us, “I know I can see my doctor at any time, the staff are quick to organise this.” Also, ‘’The staff are very good and are on hand to help me with my care when I need it.’’

People were supported to be able to eat and drink sufficient amounts to meet their needs. We received the following comments from people about the meals they received: “Very good”, “Plenty to eat”, “You always get a choice”, “The cook will always cook something else if you don’t like what’s on the menu.”

We found the general level of cleanliness and hygiene in the home to be good. There were good systems in place to help monitor standards of cleanliness.

We asked people who used the service about the skills of the nurses and support workers. They told us the staff worked very hard and knew how to do their job. They felt staff were competent.

Inspection carried out on 3 January 2013

During a routine inspection

We spoke with seven people who lived at Birkdale Park about the service they received. They told us they were happy with the way staff supported them and the care they received.

Those we spoke with said the staff knew what support they required and the staff did everything that was needed for them. One person told us, “Staff take their time and take care to respect your privacy.’’ Another person said, ‘’Staff help you when you need it.’’

We spoke with four care staff, as well as nursing staff and the registered manager. They told us they had received relevant training and felt supported by the manager and senior staff in the home.

We asked people who used the service about the skills of the nursing and care staff. They told us the staff worked very hard and knew how to do their job. They felt staff were competent.

We spoke to people about the service they received with regards to their involvement in the quality and development of the service. They told us they were asked their opinions so that their views were known. They said they were able to contact the manager if they ever had a problem with the service.

Inspection carried out on 8 February 2012

During an inspection to make sure that the improvements required had been made

We visited Birkdale Park to follow up and check whether improvements had been made following our last visit in November 2011. We had concerns about three of the outcomes for essential standards of quality and safety that the home needs to meet. These were around the planning of the care and medication management as well as overall concerns about the ability of the service to respond to regulatory requirements in a timely way and to develop the service positively.

We reviewed the nursing care of three people in some depth and found we could follow the care they were being given and this followed good practice.

We spoke with people about the staff. They told us that staff were helpful and supportive when carrying out daily care. We received positive comments about staff and their approach. We spoke with one person who said, ‘’The staff look after me very well.’’ Another person said, ‘’The staff are very kind and do not rush.’’

We spoke with several people who lived in the home about their medicines and the way they were handled. None of them raised any concerns about the way their medicines were being looked after.

Overall we found the home to have improved in all essential standards we looked at.

Inspection carried out on 23 November 2011

During an inspection to make sure that the improvements required had been made

We had concerns from our two previous visits to the service in June and August 2011 that people were not fully consulted about their care. On this visit we spoke with people who lived in the home and asked them how they were supported to consent to care and treatment. Generally they spoke positively about how staff included them in the care. They confirmed that staff asked for their consent to care and treatment as required on a daily basis regarding their personal care. We also spoke with a relative who said that they were kept up to date with any occurrences and had been consulted regarding the ongoing care of their relative.

We asked people how staff approached personal care. Those we spoke with said that staff were supportive when carrying out care and using equipment. We were told by one person that, ‘‘Staff are very kind and help me. They are patient and always explain what they are doing.’’

People spoken with also confirmed that the General Practioner [GP] visits when needed and this is arranged promptly. We saw three people who had more dependant care needs and these had good standards around personal hygiene showing that staff paid good attention to standards in this area.

We spoke with two people who told us that some aspects of care were not consistent. For example, the use of the hoist and the way that staff assisted them to move and mobilise. We still have concerns about some of the inconsistent care in the home.

We did not ask people specific questions regarding the overall management of the home although people spoken with seemed generally satisfied. They felt staff would listen and did not express any concerns about the running of the home. Because of our overall findings we still had concerns however that the home lacks consistent management in key areas.

Inspection carried out on 23 August 2011

During an inspection to make sure that the improvements required had been made

We visited Birkdale Park to follow up and check improvements made from our last visit in June 2011. At that time we had concerns about five of the outcomes for essential standards of quality and safety that the home needs to meet. These were around people’s right to be consulted about care, their right to consent to care, some nursing care practice, medication management and staff recruitment.

On the day of the site visit eight people who live in the home were interviewed and asked their views. All confirmed that they felt their views were being taken into account by staff in the decision making for the care and treatment they received at the home. Many expressed the view that they felt like they were treated with respect and dignity. People spoken with said that staff are both competent and respectful in terms of any privacy and dignity issues.

We saw three people who have more dependant care needs and all people we saw had good standards around personal hygiene showing that staff paid good attention to standards in this area. We saw that specialised equipment such as pressure relief mattresses were in use and that people looked comfortable.

We spoke with people about the staff. They told us that staff were helpful and supportive when carrying out daily care and were easily identifiable. We received positive comments about staff and their approach. This helps people to feel safe in the home.

We had concerns from our visit in June 2011 that people are not fully consulted about their care. We found that senior staff were unclear about assessing people's mental capacity and how this effects their decisions about care and how staff can support people and act in their best interest if needed. We also found inadequate care planning around key areas of care such as wound care. We set compliance actions for these to be addressed through training and better understanding. This would help ensure people’s rights are protected and they receive consistent care.

On this visit people generally spoke positively about how staff included them in the care and confirmed that staff asked for their consent to care and treatment as required on a daily basis regarding their personal care. We discussed, however, some of the people needing specific nursing care interventions and found that there were some issues that still needed more thorough assessment around people’s ability and right to consent. Care planning was not clear and staff knowledge around some key issues was also not clear. This lack of appropriate assessment and care planning may still place people at risk of inconsistent or inadequate care.

At our last visit on 19th May 2011 we found medicines to be disorganised and some medicines were being given at the wrong time. Following this visit we found some improvements but some issues had not been fully addressed. We found gaps in the medication recording, lack of adequate auditing, lack of management plans for some medication such as PRN [give when needed] and lack of clarity around application of topical creams.

Overall we recognise the improvements made to the service in meeting two out of the five essential outcomes we assessed. There have also been some improvements evidenced in the other three. We still have concerns however and will continue to follow these up with further visits to Birkdale Park.

Inspection carried out on 10 May 2011

During an inspection in response to concerns

Prior to the site visit to the home we had a concern expressed by one relative that the family had not been consulted about a key area of care for their relative. They told us that senior nursing staff had been evasive about consulting them about care and had initially been dismissive of their concerns. The care was thought not to be appropriate by the family member as the person shared a room at a critical point in their care and privacy was felt to be compromised.

On the day of the site visit most people confirmed that they felt like they were encouraged to express their views openly. They were of the opinion that these views were being taken into account by staff in the decision making for the care and treatment they received at the home. For example one person told us about they had been involved in deciding about a doctor’s visit and this had been discussed with them.

People expressed the view that they felt like they were treated with respect and dignity. They told us that staff were available to offer support and that they approached care well and were patient and supportive. They felt care staff were competent in terms of delivering basic personal care and maintained their privacy and dignity.

We spoke with one person who, although pleased with the overall level of care had an issue over the use of bedrails. They had had some discussion with staff about this aspect of care but had received conflicting information and was unsure why they were needed. They felt their dignity was compromised.

We spoke with four of the people who live in the home and discussion referred to their views on being supported to consent to care and treatment. Comments received indicate that some areas of care were more inconsistent than others. One person said that staff conferred with them about a recent referral to the GP as a visit was needed. Another was fully aware about the role of visiting professionals in their care and how this was arranged. One person was not involved, however, in the decision to use bedrails and a relative was concerned that nobody had been consulted about a change of bedroom. Full consultation is important so that people’s rights are respected.

The dependency of people living in the home can be high and we asked some people about how staff approached personal care. Those we spoke with said that staff were supportive when carrying out care and using equipment. We saw two people who have more dependant care needs and all people we saw had good standards around personal hygiene showing that staff paid good attention to standards in this area.

This shows us that people are happy with the general personal care being delivered.

We spoke with three people who lived in the home about their medicines and observed some medicines being given to people. All three people said they were happy and comfortable living in the home and they thought their medicines were given to them properly. We observed inconsistencies in the administration of medicines however and these could put people at risk.

We had mixed opinions from health care professionals who visit the home. There were some concerns expressed about how certain areas of care are managed such as wound care.

Reports under our old system of regulation (including those from before CQC was created)