Birkinshaw Manor

Birkinshaw Manor is a residential care home providing the regulated activity Accommodation for persons who require nursing or personal care for to up to 54 people. The service provides support to older people, including those living with dementia, people with a physical disability and younger adults. At the time of our inspection there were 40 people using the service.

Birkinshaw manor is a purpose-built care home offering care and accommodation for up to 54 people. The home consists of purpose-built accommodation with rooms spread over 3 floors. All rooms have en suite facilities and there are a range of communal facilities such as lounge areas, dining room, a cinema room, library and other amenities.

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

People were cared for effectively and safely. Some risk assessments needed more detail. Any safeguarding concerns were reported and investigated. There were sufficient numbers of staff to support people with their care needs, although some people commented on the high use of agency staff. The services tried to use regular agency staff members, so they were familiar with people's needs. Medicines were managed safely, and medicine records were up to date. The home was clean and tidy and appropriate infection control procedures were followed. Accidents and incidents were recorded and monitored. The provider had acted on previous recommendations regarding mealtimes and activities at the home.

People, relatives and staff told us management of the home had improved significantly. Staff told us morale had improved and there was a good working team at the home. Relatives told us they had witnessed significant improvements in care and the overall running of the home. A range of checks and audits were undertaken. Some records were not always up to date or well-maintained. We have made a recommendation about this. The service looked to involve staff and people in care decisions and worked closely with outside professionals.

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 and update

The last rating for this service was requires improvement (published 10 August 2022)

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 improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider review activities at the home and ensure that people’s mealtimes were a positive experience. At this inspection we found provider had acted on these recommendations. Activities had improved and were praised by people, relatives and staff. Meals times were appropriate to people’s needs.

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 carried out an unannounced comprehensive inspection of this service on 29 and 30 March 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance and compliance with the duty of candour regulations.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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

Recommendations

We have recommended the provider review and improve the keeping and storage of daily records and some audit records.

Follow up

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

Birkinshaw Manor is a residential care home providing personal care for up to 54 people. Accommodation is available across three floors which have adapted facilities to meet people’s needs. The second floor of the home provides specialist support for people living with a dementia related condition. At the time of our inspection there were 33 people using the service.

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

Medicines were not always managed safely. Medicines administration records did not always match with remaining stock counts of medicines. Therefore, we could not be assured medicines had always been administered as they were prescribed.

Not all areas of the environment, including furniture and furnishings were clean. In addition, some areas of the home were malodorous. A comprehensive schedule of works to be completed was in place to improve the environment and furnishings. This included plans to replace flooring. Risks relating to the environment had not been fully assessed. Staff acted following our first visit to the home, to ensure the areas of the home which were dirty were cleaned. The provider was working with an interior designer to upgrade the environment to ensure the décor met people’s needs, including those who were living with dementia.

Records were not available to demonstrate how the provider was meeting their responsibilities under the duty of candour. The duty of candour regulation tells providers they must be open and transparent with people about their care and treatment, as well as with people acting on their behalf. It sets out some specific things providers must do when something goes wrong with someone's care or treatment, including telling them what has happened, giving support, giving truthful information and apologising.

An effective governance system was not fully in place. Shortfalls identified during the inspection had not always been highlighted by the provider’s quality monitoring system. In addition, where audits had identified issues, action had not always been taken to implement improvements.

Systems were in place to recruit staff safely. The provider used a tool to assess staffing levels which was based on the dependency needs of people. However, we did receive mixed feedback about staffing levels from staff, people and relatives. In addition, during feedback we discussed staff deployment during busier times for example mealtimes and suggested there was management oversight to ensure staff were correctly deployed.

The provider had a safeguarding system in place. Staff raised no concerns about safeguarding practices in the home.

People were supported with their nutritional needs. Records relating to what people ate and drank did not always accurately reflect people’s dietary intake. We have made a recommendation about this.

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.

People gave positive feedback about the caring attitudes of staff. Care plans included information about people’s choices and preferences in relation to their wishes for their care.

Due to the impact of COVID-19, social activities had not always been carried out as planned. On occasions the activities coordinators were redeployed to cover care shifts. However, people spoke very positively about both activities coordinators and the support they provided.

Formal complaints were recorded. We discussed with the registered manager about recording informal concerns centrally so any trends and themes could be easily identified, and action taken.

Systems were in place to involve people, relatives and staff in the running of the home. Staff worked with health and social care professional to help ensure people’s needs were met.

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

Rating at last inspection

This service was registered with us on 9 November 2021 and this is the first inspection.

The last rating for the service under the previous provider was inadequate, published on 20 July 2021.

Why we inspected

This was a planned inspection based on the date of the provider’s registration with CQC.

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

Enforcement and Recommendations

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 three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, duty of candour and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

We have also made recommendations in the effective and responsive key questions. Please see these sections for further details.

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.