Birdscroft Nursing Home

Updated 1 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

Two inspectors and an Expert by Experience carried out this inspection.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Birdscroft Nursing home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Birdscroft Nursing home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 6 people who used the service and 4 family members. We spoke with 5 members of staff including the registered manager. We reviewed a range of records. This included a review of 5 people's care and medicine records. We looked at staff files in relation to safe recruitment practices. A variety of records relating to the management of the service and quality assurance were reviewed including accident and incident records and audits. We sought feedback from healthcare professionals who work with the service.

Updated 1 September 2023

About the service

Birdscroft Nursing home is a residential care home providing personal and nursing care to up to 28 people. People living at the service had a range of needs including dementia, nursing needs and needs associated with older age and frailty. At the time of our inspection there were 25 people using the service.

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

Whilst improvements were made since the last inspection, we found the governance systems of the service did not support the service to consistently improve and sustain safe care delivery. There were quality assurance processes in place, but these did not always identify areas for improvement including potential infection risks and environmental issues.

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. However, the policies and systems in the service did not support this practice. There was little evidence to support how best interest decisions were made and Capacity assessments were not always recorded. We made a recommendation that the registered manager should consistently and accurately apply the principles of the Mental Capacity Act 2005.

There were sufficient appropriately skilled staff to meet people's needs and keep them safe. People and relatives told us there were enough staff to care for their family members. However, we observed that a reduction from 6 staff to 5 in the afternoons meant they had little time to interact socially with people. There was a safe staff recruitment process in place. Staff received appropriate training, support and development to enable them to meet people's needs.

Some care records lacked detail of people’s support needs and did not always include risk mitigation. However, people were supported by nursing and care staff who demonstrated a good understanding of people’s support needs. Healthcare professionals told us people were referred appropriately and with comprehensive details about the presenting problem. Staff followed their recommendations to ensure good health outcomes for people. Notifications were completed to inform CQC and other outside organisations when events occurred.

People and their family members spoke positively about staff engagement and told us they were treated in a caring and respectful way. People and their relatives had the opportunity to express their views on their care and staff worked in a way which supported people's dignity and privacy.

There was an activities programme which was developed in conjunction with people who were encouraged to make suggestions and state their preferences. People spoke positively about the culture at Birdscroft Nursing Home. They told us that communication with the registered manager and general staff team was good and they felt listened to. Staff told us they felt their work was valued and the registered manager supported them to progress in their careers.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 September 2022) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations and remains rated requires improvement. This service has been rated requires improvement for two consecutive inspections.

This inspection was carried out to follow up on action we told the provider to take at the last inspection. You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified a continuing breach of good governance at this inspection.

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 from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.