Birdscroft Nursing Home

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.

Birdscroft Nursing Home is a residential care home registered to provide personal and nursing care to up to 28 people. People living at the service have a range of needs including physical disabilities, nursing needs, and needs associated with older age and frailty. At the time of our inspection there were 26 people using the service.

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

Staff levels did not take into account people’s changing needs and people told us there were not enough staff to support them in a timely way. This impacted on the length of time it took staff to assist them with their personal care.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. People's consent to care was not always evidenced and staff’s knowledge of the Mental Capacity Act 2005 was inconsistent. Staff training was not effective in ensuring consistent good practice within the service.

There were insufficient meaningful activities provided for people and many people and their family members told us there was a general lack of stimulation in the home. Some care plans were found to contain conflicting information and at times lacked details about the person and their social history. They did not always contain sufficient guidance for staff around how to support people according to their needs and preferences. People knew how to make a complaint and their end of life preferences were recorded.

Quality assurance processes were not effective in identifying and delivering required improvements to the service. This meant people were at risk of not receiving a consistent or safe service in line with their needs. There was a lack of robust management oversight of the service. However, people and staff spoke positively about the registered manager and deputy manager.

Staff understood their responsibilities in safeguarding people from abuse and knew how to report any concerns they had. Medicines were managed safely and people’s health care plans followed National Institute for Health and Care Excellence guidelines.

The home was clean and hygienic and staff maintained effective systems of infection prevention and control (IPC). The provider exercised safe recruitment practices and medicines were safely managed.

People told us staff were kind and caring though some told us they were not always supported to maximise their independence. Family members told us their relatives were well groomed and staff supported them to maintain their appearance. We saw how staff engaged positively with the people they supported during our inspection and treated them with kindness and respect.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support:

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care:

Care was not person-centred and did not always promote people’s dignity, privacy and human rights. People were left alone for extended periods of time in their room and not all staff had an understanding people’s preferences around care.

Right Culture:

Ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services led confident, inclusive and empowered lives. The provider did not regularly review or consider the appropriateness of service for people.

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 13 January 2018.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

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 and will take further action if needed.

We have identified breaches in relation to low staffing levels, low levels of compliance with staff training and lack of meaningful activities. We also found there was disproportionate use of restraint with one person, as well as a lack of robust provider and management oversight and quality assurance.

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.

Birdscroft 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. Birdscroft is registered to provide accommodation for persons who require nursing or personal care for up to 28 people. There were 26 people living at the service 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. The registered manager was at the home during the time of our inspection.

We last carried out a comprehensive inspection of Birdscroft in November 2016 where we found the registered provider was in breach of two regulations. These related to the safe management of people’s medicines and the effectiveness of the provider’s quality assurance systems. Following this inspection the registered provider sent us an action plan of how they would address these two issues.

We completed a focussed inspection in June 2017 to check that the provider had taken action to address the concerns we had raised. At that inspection we found that both concerns had been addressed by the provider. At this inspection we found that the care and support people received had continued to improve under the guidance of the registered manager.

The inspection took place on 29 November 2017 and was unannounced.

There was positive feedback about the home and caring nature of staff from people who live here. The registered manager had been in post for over six months, and had made many positive changes to the standard of care people received. Quality assurance processes were now picking up day to day issues, so that corrective action could be taken.

People were safe at Birdscroft Nursing Home. Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or Care Quality Commission.

Risks of harm to people had been identified and clear plans and guidelines were in place to minimise these risks. The home was clean, and staff practiced good infection control measures, such as hand washing and correct use of personal protective equipment. In the event of an emergency people would be protected because there were clear procedures in place to evacuate the building.

There were sufficient staff deployed to meet the needs and preferences of the people who lived at the home. There had been a recent issue with staffing, but the registered manager had taken action to prevent a reoccurrence. The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people in the home. Staff received a comprehensive induction and ongoing training, tailored to the needs of the people they supported. People’s nursing needs were met by competent staff.

People received their medicines when they needed them. Staff managed the medicines in a safe way and were trained in the safe administration of medicines. Internal audits continually reviewed staff performance around medicines, and appropriate actions were taken where issues were raised.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. Staff were heard to ask people for their permission before they provided care. Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People had enough to eat and drink, and specialist diets either through medical requirements, or personal choices were provided. People who required specialist equipment to help them eat were supported by nursing staff to ensure this was done safely.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. When people’s health deteriorated staff responded quickly to help people and made sure they received appropriate treatment. People were supported at the end of their lives to have a dignified death.

People received the care and support as detailed in their care plans. The staff knew the people they cared for as individuals, and were positive in their interactions with them. Staff treated people with kindness and respect. People were involved in their day to day care decisions.

People had access to activities in the home and the registered manager was reviewing the possibility for arranging more external trips for people.

People knew how to make a complaint. Where complaints and comments had been received the staff had responded to try to put things right.

We carried out an unannounced comprehensive inspection of this service on 28 November 2016. At that inspection breaches of legal requirements were found. After that comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches in medicines management, good governance and provider management oversight by 30 April 2017.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Birdscroft Nursing Home on our website at www.cqc.org.uk.

The provider had taken appropriate action and addressed all of these concerns. The service now required a period of stability for these changes to be embedded and sustained

There was not a registered manager in post. A new manager was in post, and in the process of applying to become registered with the CQC. 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 told us they were happy living here. One person said, “Staff are good, very caring.” Another person said, “The food is really good, my room is warm when it is cold outside, and my bed is comfortable.” Staff told us they were happy in their work.

People were safe at Birdscroft Nursing Home. There were sufficient numbers of staff who were appropriately trained to meet the needs of the people who live here. Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or the police.

Staff managed the medicines in a safe way and were trained in the safe administration of medicines. People received their medicines when they needed them. The provider’s internal quality assurance processes had identified that some improvements were required in the way some staff managed medicines. They had taken appropriate action to address the issues.

Risks of harm to people had been identified and clear plans and guidelines were in place to minimise these risks. In the event of an emergency people were protected because each person had a plan which detailed the support they needed to get safely out of the building.

Staff recruitment procedures were safe to ensure staff were suitable to support people in the home. The provider had carried out appropriate recruitment checks before staff commenced employment. They had also checked to ensure staff were eligible to work in the UK.

The provider had effective systems in place to monitor the quality of care and support that people received. Quality assurance records were kept up to date to show that the provider had checked on important aspects of the management of the home. The manager had ensured that accurate records relating to the care and treatment of people and the overall management of the service were maintained.

There was not 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. The current home manager had been in post for two months and had submitted his application to become the registered manager to CQC.

The inspection took place on 28 November 2016 and was unannounced. At our last inspection in February 2015 we identified three breaches in the regulations, and areas of the home that required improvement. The registered manager and provider gave us an action plan on how they would address these issues. At this inspection we found that some, but not all of the areas of concern had been addressed.

The lack of good leadership after the departure of the registered manager had an impact across four of the five key areas we looked at. It affected the safety of the home as medicines where not managed safely; how effective the home was at meeting people’s needs; how responsive staff were; and how well the home was led. We have identified three breaches in the regulations. This is the same amount compared to our last inspection showing the lack of leadership was failing the people who live here. You can see what action we have asked the provider to take at the back of the full version of this report.

Staff did not manage the medicines in a safe way. Safe systems of work were not followed so people could not be assured they had the right medicines at the right time. Staff had made decisions to alter the format of medicines by crushing them. This was done without consulting a GP or pharmacist to check if this could affect the effectiveness of the medicine.

The provider did not have effective systems in place to monitor the quality of care and support that people received. Quality assurance records were completed to check on important aspects of the management of the home; however these had not identified the issues found during this inspection. The home manager had not ensured that accurate records relating to the care and treatment of people and the overall management of the service were maintained. This was an area of improvement we had highlighted at our previous inspection.

People were not always supported to have access to healthcare professionals to maintain good health. The management of pressure wound care was variable, with concerns being raised about the accuracy of, and lack of records to manage peoples nursing needs. These concerns were also identified a week after the inspection by a visiting tissue viability nurse, showing the management had not acted quickly to improve the support people received.

People received the care and support they needed, however the care plans did not always reflect peoples current needs. Care plans were based around the individual preferences of people as well as their medical needs. People and relatives were involved in reviews of care, but these reviews did not always result in a change of the support plan to reflect current needs. People were at risk of not getting care they really needed as staff who may not be familiar with people (such as agency staff) would not have access to correct information.

The staff were kind and caring and treated people with dignity and respect. However the failures across the home demonstrated there was a lack of care and attention to following safe systems of work, and to meet the requirements of the health and social care act. There was positive feedback about the home and caring nature of staff from people who live here, and their relatives.

There were sufficient numbers of staff who were appropriately trained to meet the needs of the people. The manager regularly reviewed staffing levels to ensure they met the needs of people. Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or the police.

In the event of an emergency people were protected because there were clear procedures in place to evacuate the building. Each person had a plan which detailed the support they needed to get safely out of the building in an emergency.

The provider had carried out appropriate recruitment checks before staff commenced employment, to ensure they were safe to work with people who may be at risk.

Staff received a comprehensive induction and on-going training, to ensure they could meet and understand the care needs of the people they supported. Staff received regular support in the form of annual appraisals and formal supervision to ensure they gave a good standard of safe care and support.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People had enough to eat and drink, and received support from staff where a need had been identified. People’s individual dietary requirements where met.

People had access to a wide range of activities that met their needs. Activities were varied and based on people’s interests.

People knew how to make a complaint. When complaints had been received these had been dealt with quickly and to the satisfaction of the person who made the complaint. Staff knew how to respond to a complaint should one be received. People and relatives were encouraged to give feedback about the home, via surveys and regular meetings. The manager and provider listened and took action where required.

People told us they felt safe in the hands of staff at Birdscroft, and when asked if the home was kept clean and fresh, all those we spoke to said it was. One added "No unpleasant odours."

We asked people if they received the help they needed in a timely way and we were told they did, though additional comments included "Mostly. On the odd occasion you have to wait if several people want help at the same time." When we asked people's opinions on the overall quality of the service comments ranged from "Eight out of ten and moving in the right direction" to "Fairly good."

All those we spoke to said they would know how to make a complaint and we were told the manager "Is on the ball" and would deal with any concerns personally.

We saw that staff spoke to people respectfully and saw that staff were knocking on people's door's before they entered. During our observations we saw that people were given choices regarding where to sit and people were able to move around the home freely. However, later in the morning we found that several people were still in bed waiting to have there personal hygiene needs met. One person told us "I always get left in bed as they never have enough staff on." We saw that not all people had access to their call bells to alert staff when they needed assistance. Some people also had no access to fluids to enable them to drink a sufficient amount.

We observed the lunchtime service and saw that people were offered a choice of two meals. One person told us "The food is ok here but it could be better." A relative told us that the chef was not reliable and that the manager and care staff had to do the cooking sometimes. There was no chef available during our visit on 26 March 2013. We saw that people were not always getting the support that they needed. One relative told us "The new manager has made some improvements but staffing is a big issue."

We found shortfalls with all aspects of the inspection which we have detailed within the report.