Staveley Birkleas Nursing Home

Updated 1 March 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 22 January 2018 and was unannounced. The inspection team consisted of two adult social care inspectors 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 Expert by Experience had experience of older people’s services.

Prior to the inspection we reviewed recent notifications received from the provider and other intelligence we had received from professionals and members of the public. We also spoke with the local authority safeguarding and commissioning teams. We asked the provider to complete a Provider Information Return (PIR. The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.” This was returned to us in a timely manner and we used the information contained within to help plan the inspection.

We spoke with nine people who used the service and three relatives who were visiting the home at the time of our visit. We observed care interactions in the communal lounges within the home. We also observed the lunch time period in the dining room on the ground floor.

We looked at five people's care files, medicine records, staff rota's and incident forms. We spoke with the registered manager, a support manager, two clinical leads, a nurse, six care staff, the activities co-ordinator and the cook. We also received feedback from three professionals who work with the service.

Updated 1 March 2019

Staveley Birkleas is a nursing home. People in nursing homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Staveley Birkleas accommodates 60 people in one adapted building. On the day of the inspection there were 50 people living in the home.

We undertook an unannounced comprehensive inspection of Staveley Birkleas on 22 January 2019.

At the last inspection in May 2018 we found the provider was in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities 2014) Regulations. This was in relation to 'Safe Care and Treatment' and 'Good Governance'. Following the inspection, the provider sent us an action plan stating how they would improve the service. At this inspection we found improvements had been made and the service was no longer in breach of regulation.

A registered manager was not in place. A manager had been recruited who was going through the CQC registered managers' assessment process. 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 the last inspection we rated the safe domain as inadequate. At this inspection we found the safety of the service had improved. However, we would need evidence that this could be sustained over time before we were fully assured the service was consistently safe.

People said they felt safe using the service. Overall, risks to people’s health and safety were assessed and mitigated and clear care plans were in place to guide staff. Safety incidents and safeguarding matters were appropriately managed and the service used any incidents to help improve the service. The premises were safely managed and were adapted to the needs of the people who used the service.

Medicines were managed in a safe manner although the service needed to ensure the recording of topical medicines such as creams was recorded in a consistent manner.

There were enough staff deployed to ensure people received prompt care and support including the provision of one to one hours. Staff were recruited safely to help ensure they were of suitable character to work with vulnerable people, with people who used the service involved in this.

Staff received a range of training which was relevant to their role. This was sourced through a variety of means including through developing relationships with local healthcare professionals. Staff said they felt well supported.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The registered provider’s policies and systems supported this practice.

People had access to a suitable range of food and drink and their nutritional needs were monitored appropriately by the service.

People’s healthcare needs were assessed and the service worked with a range of professionals to help meet those needs. People had clear and detailed care plans in place which were subject to review. People felt involved in decision making relating to their care.

People were cared for by staff who displayed kindness and compassion and treated people with dignity and respect. People’s feedback about staff was very positive.

People’s independence was promoted through care planning, and the provision of activities, exercise and physiotherapy.

People had access to a broad range of activities. The service had developed strong links with the local community and this combined with leisure facilities owned by the provider ensured plenty of opportunities were available to people.

People’s complaints were listened to and used to make improvements to the service. People provided very good feedback about the overall quality of the service and said it was well led. The service had a clear set of values centred around providing high quality person centred care. Staff understood these values and were true to them. Staff said that morale was good and that the service had improved over recent months.

Good governance systems were in place to assess, monitor and improve the service. Systems put in place by the new manager had led to an improvement to the overall quality of the service.