All inspections: Birkin Lodge Care Home

Birkin Lodge Care Home provides care and accommodation to up to 50 older people. The home is set over three floors providing a combination of residential care and nursing care. People that use the service have a range of care needs and complex health needs requiring care from registered nursing staff. The service at Birkin lodge is provided by the Brighterkind group, which is part of Four Seasons Health Care Group.

This inspection was carried out on 22 February 2016 by three inspectors. It was an unannounced inspection. There were 24 people using the service at the time of the inspection. Building work was underway at the service to refurbish the premises. Two of the three floors had been refurbished and work was due for completion on the third floor in March 2016.

There was a new manager in post who had joined the service the previous week. The manager was not yet registered with the Care Quality Commission (CQC), but told us they were in the process of applying. A registered manager is a person who has registered with the CQC 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 May 2015, the service was in breach of regulations relating to the provision of personalised care, managing risks to individuals and effective monitoring and improvement of the service. At this inspection we found improvements had been made to these areas and the requirements of the regulations met. However, practices need time to be embedded.

At this inspection we found that staff did not consistently follow safe practice for administering and managing people’s medicines. Systems for administering medicines did not ensure that people received their prescribed medicines on time.

Records were not completed accurately. There were gaps in people’s care plans about their preferences to ensure they consistently received a personalised service.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm. Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.

There were sufficient staff on duty to meet people’s needs. Staffing levels were calculated and adjusted according to people’s changing needs. There were thorough recruitment procedures in place to ensure staff were suitable to work with people. Regular checks were made to ensure nursing staff remained registered and safe to practice.

Staff were knowledgeable and competent to meet people’s needs. They had the opportunity to receive further training specific to the needs of the people they supported. All members of staff received regular one to one supervision sessions. Staff felt supported in their roles and were clear about their responsibilities. This ensured they were supported to work to the expected standards.

Staff sought and obtained people’s consent before they helped them. They understood the requirements of the Mental Capacity Act (MCA) 2005 when helping people to make decisions. The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options were considered.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People praised the food they received and they enjoyed their meal times. Staff knew about and provided for people’s dietary preferences and restrictions. Nursing staff monitored people’s health needs and made prompt referrals to other health care professionals when needed.

The premises had been recently refurbished and were appropriate for the needs of the people living there. The risk of the spread of infection in the service was managed effectively.

Staff understood people’s preferences and delivered care in a personalised way. Staff knew people well and provided a caring service. People had their privacy and dignity respected and staff recognised their right to independence.

People were involved in their day to day care. People’s care plans were reviewed with their participation and relatives were invited to attend reviews that were scheduled. People were at the heart of the service. Clear information about the home, the facilities, and how to complain was provided to people and visitors.

People were involved in the planning of activities that responded to their individual needs. A broad range of activities was available that ways to keep people occupied and stimulated.

Staff told us they felt supported by the manager and supported to provide a high quality service. The manager was open and transparent in their approach. Emphasis was placed on continuous improvement of the service. Improvements had been made to the culture of the service to ensure people received personalised care. The changes need to be embedded in staff practice to ensure they are sustained.

The registered provider kept up to date with any changes in legislation that might affect the service and carried out comprehensive audits to identify how the service could improve. They acted on the results of these audits and made necessary changes to improve the quality of the service and care.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

This inspection was carried out on 26 May 2015 and was unannounced. There were 32 people using the service at the time of our inspection, some of whom had a physical disability and some people living with dementia. The home provides personal and nursing care.

At our previous inspection on 11 and 12 February 2015 we found breaches of nine regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These correspond with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which came into force on 1 April 2015.

We issued three warning notices in relation to care and welfare, quality assurance and not having enough staff. We told the provider they must improve in these areas by 6 April 2015.

We also found a further six breaches of regulation. These were in relation to nutrition and hydration, obtaining consent, staff training and support, infection control, safety of the premises and record keeping. We asked the provider to tell us what action they were taking. The provider sent us an action plan and told us the regulations would be met by 3rd July 2015.

At this inspection we found that some improvements had been made towards meeting the warning notices, however, the provider had not completed all the actions they told us they would take. The provider was continuing to breach regulations in respect of care and welfare and quality assurance. We found that the impact for people using the service had reduced and people told us the care had improved.

Whilst carrying out this inspection we found that the provider had fully met five of the requirement actions ahead of their 3 July timescale. We found that there were still some breaches in record keeping and therefore the requirement action in respect of record keeping has remained in this report. We found a further breach of regulation in relation to providing a personalised service.

The registered manager was on long term leave from the service. A registered manager is a person who has registered with the Care Quality Commission to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. An acting manager had been appointed and had been in post for four weeks.

People said the service they received had improved since our last inspection. Comments from people included, “I’m quite satisfied with the way it is run” and “Things seem to be turning around.” People said staff were caring and that there were more staff available to meet their needs. Comments included “We don’t have to wait so long now”, “They are very good at what they do, they help me when I need it” and “I can’t wish for better carers”. However, people felt that they did not have enough links with the local community or opportunities to go out.

The risk of people developing a pressure wound had reduced and staff had received further training to effectively manage these issues and prevent them occurring again. However there were no checks made of pressure relieving air mattresses to ensure they were working effectively for people’s individual needs.

More staff were now available on each shift and the allocated numbers had been increased. Increases in staff numbers meant that staff had more time to engage in conversation with people throughout the day. However, some staff were still task centred and mostly engaged with people only when carrying out care tasks with them.

Improvements had been made to the training staff received. Nursing staff had received further training in managing the risk of pressure wounds. Staff had been trained in moving people safely and people were helped to move safely and in a way that promoted their comfort.

The risks associated with people losing weight had not been consistently managed. Two people who required their weight to be checked each week had only had this done monthly. This meant that nursing staff could not quickly identify if their weight loss was continuing and take action.

The provider had made changes to the values of the service and had begun to put these into practice, but these had not yet been embedded into the culture of the service.

People who spent most of their time in their bedroom did not have plans in place to meet their social needs.

Staff knew people well and treated them kindly. Most staff treated people with respect and upheld their dignity. However, we saw one occasion where a person’s privacy was not respected whilst using the toilet and people’s dignity was not always upheld whilst being hoisted.

People living with dementia did not have their needs properly assessed or planned for. They did not have plans in place to help them find their way around the service or to support them when they were distressed. Not all staff had received training in dementia to support them to do this.

The systems for monitoring the quality and safety of the service had improved, however, the acting manager had not completed the checks they had told us they would make on the effectiveness of the call bell system. Accurate and complete records were not consistently kept. This meant that the acting manager could not check that people were getting the care they needed.

We found that improvements had been made to the cleanliness of the premises and to the systems for managing the risk of the spread of infection in the service.

There were effective systems in place for checking the safety and security of the premises.

People’s medicines were managed in a safe way and people received the medicines they needed.

All staff had been supervised by a member of the management team to ensure they had the skills to carry out their role.

People consented to their care and treatment before it was provided. The requirements of the Mental capacity Act 2005 were met when people could not give consent or make their own decisions.

People were provided with sufficient amounts to eat and drink to meet their needs.

People had their specific health needs planned for and met, for example people with diabetes who required checks of their blood glucose levels.

You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 11 and 12 February 2015 and was unannounced. The service provides accommodation to up to 42 older people who have nursing or care needs. The home is set over three floors; two of which providing nursing care support, the other providing care in a residential setting. At the time of the inspection there were 37 people living at the service, 26 of which required nursing care.

There has been a history of non-compliance with this service since September 2014 when we served compliance actions in relation to infection control and staffing numbers. At this inspection we found the provider had not taken steps to meet the requirements of the compliance actions, and we found further breaches of regulations.

At the time of our inspection the service had not had a registered manager in post since 8 March 2013. The service was being managed by the organisation’s regional support manager who had been appointed to the home as an interim manager since December 2014. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated regulations about how the service is run. The regional support manager and regional manager were in attendance during the inspection.

People and relatives told us that they felt safe living at the service; however the service was not always safe. Staff demonstrated an understanding of what constituted abuse and how to report any concerns. The service had safeguarding procedures in place and was working with the local safeguarding team to ensure people were protected from abuse.

There were not enough staff on duty to meet people’s needs. Some people did not receive food or drink during the first morning of our inspection because there were not enough staff to ensure this happened.

There was a formal tool in place to assess the number of staff required to fully meet people’s care and support needs. This was based on the dependency needs of people assessed by senior staff. We found that some staff lacked the skills and competencies to assess people’s needs accurately; therefore the information used to complete the staffing levels tool was not accurate.

Staff told us they had completed an induction training programme, which included shadowing experienced staff, but the service did not have a completed induction programme to show us at the time of the inspection. Mandatory training had been provided but staff one to one meetings with their manager and appraisals were not up to date to show that staff individual training and development needs had been discussed. There was a training programme in place and staff were kept updated with refresher training. However we found that some staff did not have the skills and competencies needed and did not apply their training in practice. Although this had been identified by the manager there was no records in place so show that the staff were being supported to improve their skills. We found that some people were living with dementia and staff had not received any training to increase their understanding of this.

People told as that they had some difficulty understanding the staff whose first language was not English. They said that communication could be an issue at times. Relatives also told us that communication could be improved. The service was taking action to address these issues and there was a programme in place to support staff with their communication skills and to improve their language and writing skills. However this was only starting on the day of the inspection, even though the some of the staff had been employed for up to four months.

Staff did not follow infection control measures when changing people’s dressings, such as, wearing protective aprons when carrying out these procedures. There were insufficient supplies of disposable gloves in people’s rooms to ensure that these were easily accessible at all times. Staff were not handling soiled linen in line with infection control procedures. People did not have individual hoist slings to reduce the risk of infection.

Risk associated with people’s care and support had been assessed, however in some cases the moving and handling risk assessments did not have full guidance about how these risks could be minimised. People had access to equipment to meet their needs. There were environmental risk assessments in place to help make sure the premises were safe, and systems in place to ensure that staff knew what to do in the event of a fire.

Accidents and incidents were recorded and some action had been taken to reduce the risk of further occurrence, however the events had not been analysed to look for patterns and trends to help reduce further occurrences.

People's medicines were not always stored safely. There was an over stock of some medicines which had not been returned to the pharmacist. Medicine records were not being completed properly to confirm people had taken their medicines. We observed medicines administration and found that medicines were being given to people safely.

There were insufficient details and information about obtaining people’s consent and involvement in their care planning, including assessments of people’s mental capacity and making decisions in people’s best interests. Care plans recorded that people had given their verbal consent, such as, for the use of bed rails but there was no record to show how this decision was made.

People did not always receive a diet that met their needs, or protected them from risks associated with not eating or drinking enough. Records did not confirm that one person was receiving a diabetic diet even though they were. People who needed their food and fluid intake monitored did not have records in place to show this had happened.

Systems in place to monitor and check people’s health care needs were not effective. Pressure ulcers had not been assessed correctly to ensure effective action was taken in a timely manner. Staff did not have a full understanding of how to assess and complete the documents to assess people’s skin integrity. People had been referred to the appropriate health care professionals, such as dieticians and tissue viability nurses, but there were delays in referrals which impacted on people’s health.

People and relatives told us the staff were kind and maintained their privacy and dignity. They said the staff were always caring. Staff supported people to go where they wished within the service. People and relatives told us that they were able to visit at any time.

People’s needs were assessed before they came to live at the service; however records did not confirm how people were involved in their assessment or that people were consulted about how they wanted their care to be delivered.

Not all care plans had a full personal history of the person to give staff a full understanding of what was important to them. Care plans and risk assessments had not always been updated to reflect people’s changing needs.

People and relatives told us that they had the opportunity to voice their concerns. A customer satisfaction survey had been sent to people last year and results had been summarised, however there was no record to show how people using the service had been advised of the outcomes, or what, if any, action was needed to improve the service.

We were told by the regional support manager that there were monthly residents meetings, which also gave people the opportunity to give feedback, however there had not been a meeting since August 2014. There were dedicated staff hours for activities and people told us that they enjoyed the singing and the local church visits, but would like the opportunity to go out more.

There was information on display to advise people how to complain but this was not in any other format to support people who may be partially sighted. Not everyone had access to a copy in their room and the complaints procedure did not include the full information about who people could contact outside of the service if they were not satisfied with the outcome of a complaint. People and their relatives were confident in how to raise issues, although some relatives were not aware who the manager of the service was.

The service was not well led. There were systems in place to monitor the quality of care and some of the shortfalls in this inspection had been identified by the regional support manager but there was a lack of action to ensure that these shortfalls were being addressed to improve the service. Staff told us they did not feel supported. The staff were not aware of the visions and values of the organisation or involved in the continuous development of the service.

The providers were not able to produce all of the documents needed for the inspection and records were not always easily accessible. Records were not always accurate and up to date, and records such as food/fluid charts had not been completed properly and there were gaps in the recording in the medicine records. There were limited systems in place to measure and review the delivery of care to people.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

This inspection was carried out by two adult social care inspectors. Some people living at the home had complex needs and were not all able to tell us about their experiences. In order to get a better understanding we observed care practices, looked at records and spoke with staff and visitors. The focus of this inspection was to answer our five key questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well-led?

Below is a summary of what we found. The summary describes what people, visitors and staff told us, our observations during the inspection and the records we looked at. As part of this inspection we spoke with 10 people who lived at the home, two visitors, registered nurses, care staff and housekeeping staff. We also spoke with the manager.

If you want to see the evidence supporting our summary please read the full report.

Is it safe?

There were insufficient qualified, skilled and experienced staff to meet people's assessed needs. The home was unable to demonstrate how staffing levels were based on individual care needs. This was because the home had no specific assessments or dependency tool in place for calculating staffing levels. People and staff we spoke with confirmed that staffing levels were stretched and staff were under pressure. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Birkin Lodge Care Home employed a dedicated team of housekeepers and laundry assistants who worked throughout the home. The home had recently received media coverage due to the outbreak of bed bugs. The home had taken appropriate action to manage the outbreak. A clear action plan had been implemented and the home had worked closely with pest control and environmental health agencies. However, unpleasant odours were smelt throughout the inspection. A compliance action has been set in relation to this and the provider must tell us how they plan to improve

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). This is where restrictions may be placed on some people to help keep them safe. On the day of the inspection, one person was under a Deprivation of Liberty Safeguard. The home had worked in conjunction with the local authority and documentation confirmed that this person was deprived of their liberty in their best interest.

Is it effective?

Systems were in place to monitor, assess and improve the quality of the care provided. Feedback was regularly obtained from people, their relatives and staff. This feedback was reviewed and actions taken to improve the standards of care provided.

Training records confirmed that staff had received the appropriate skills and knowledge to safely deliver care and support to people. Care staff received regular supervision. This meant that their knowledge and practice was regularly assessed and they had the opportunity to discuss any concerns.

Individual care plans were devised and developed. Care plans looked at specific areas of health and wellbeing. These included mobility, breathing, personal care and medication. Care plans were reviewed on a monthly basis. Risks to people were assessed and individual risk assessments developed. Risk assessments included falls, pressure damage and malnutrition.

Is it caring?

Staff interactions demonstrated that people were treated with kindness and respect. People spoke highly of the care staff and the care they received. Staff demonstrated a sound understanding of the principles of privacy and dignity. They told us how they provided personal care which respected people's rights, whilst promoting their autonomy.

People's religious and spiritual needs were respected and promoted. On the day of the inspection, Holy Communion was taking place. The home worked closely with local priests, reverends and ministers.

People were dressed in accordance with their own wishes. People had their hair neatly done. Women had their jewellery and make up on as they so wished. Rooms were made individual to the person. We saw that people had their personal pictures and ornaments around them.

Is it responsive?

People's needs had been assessed before they moved to Birkin Lodge Care Home. This meant that the home had the skills and facilities to meet their identified needs. Where people's needs had changed or specialist advice was required, we saw the home had responded appropriately.

Information was available on how to make a complaint and people told us they would feel happy approaching staff with any concerns.

Is it well-led?

A registered manager was not in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. A manager was appointed but they had not yet registered with the commission. The name of the previous registered manager appears on this report. They have not yet informed the commission they are no longer the registered manager of Birkin Lodge Care Home.

Management had a quality assurance framework in place to monitor, review and improve the running of Birkin Lodge Care Home. For example, health and safety audits were completed. A representative for the provider visited the home on a monthly basis. These visits fed into the home's quality assurance framework.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. At the time of our inspection the provider did not have a registered manager in post

We spoke to people living at Birkin Lodge who told us 'the staff are helpful when I need help', 'The food is good, good sized portions' and 'I like it here'. Relatives gave us mixed views: 'the care is exemplary, I couldn't ask for anyone more', 'I would recommend Birkin Lodge', '(my relative) doesn't want for anything'. Other relatives said 'the call alarms go off for a long time', 'I don't think the handover is good, often I feel like my questions aren't welcomed'.

Through our observations and speaking with people we saw that people were able to make choices about the care they received and their consent was sought by staff. We saw that interaction was respectful and intervention. There were detailed records pertaining to people's care and health. People appeared suitably cared for. We looked at information related to the safeguarding of the people living at Birkin Lodge; there was a clear procedure in place and both staff and management had had training. Staff told us they were trained, supervised and supported. We saw evidence of training; a wide range of courses had been completed. Temporary manager support was in place.

We used a number of different methods to help us understand the experiences of people using the service. We spoke individually with seven people using the service and with two visitors, read records including care plans and observed people during the day. This included observations of how people interacted with staff.

People told us they liked living at Birkin Lodge they said the atmosphere was welcoming and friendly and they felt at home. They told us 'You belong immediately you come, everyone is welcoming' and 'It's an old fashioned family home and well run'.

The people we spoke with said they were given choices about their daily routines, such as when to get up and go to bed, what to eat and what to do each day. They said they had opportunities to take part in activities if they chose to and were involved in making decisions about the service. They said they could choose to attend the regular resident's meetings and people who attended said the meetings addressed any items they raised.

People told us that staff were kind and caring and when they needed assistance with anything they responded quickly. People told us 'I like the staff, I like some more than others and they are special' and 'They could not be better'.

People told us that they liked the meals at the home and there was always a choice. They said 'I can choose meals and if I do not like what is on the menu they will prepare what I want' and 'I cannot eat dairy products but they always have something for me'.

People liked their rooms and said the rooms and other parts of the building they accessed were kept clean. One person who preferred to stay in their room said staff were often passing by and there was plenty of company and people to see.

People were complimentary about the service overall. Comments made by relatives included 'I can't speak highly enough about staff, they are patient, extremely helpful and do all they can' and 'I can't fault them'.

People told us they missed the activities coordinator. 'We're fed up with it! We used to have bingo and prizes.'

One lady said 'I should be walking on a zimmer every day, but I'm not. I don't know why ' it's all a waste of time.'

One person we spoke to said 'I prefer to spend my day in my room, but they do take me into the garden should I want to.' Another person told us 'I can spend my day how I like. The staff here are really marvellous. We're now introduced to new staff personally; they come round to speak with us when they start.' The person we spoke to about this thought this was respectful.

Another person said 'If you don't like the food you can order another. It's very relaxed.'

Someone told us that the activities co-ordinator is 'good with nails ' we've missed her recently. She's been off for the summer. People come in to entertain ' we've had a couple singing recently. There's been talk of a visit to the sea, but nothing's happened yet. We had a fete last weekend, it was very good actually.' Another person said 'we have quite a lot of fun.'

One person told us 'I feel perfectly safe here.'

Someone said 'The cleaning's got better; my floor in the bathroom is mopped daily. The room is cleaned daily and my windows cleaned for frequently.' Another person said 'They clean my room and bathroom every day, the carpet is cleaned monthly.'

One person told us 'Oh it's much improved. I've got new furniture and a reading lamp as they know I read a lot. Now my furniture matches.' Another person said 'The rest of the house has been done up, it looks very good now.'

Someone else said 'they've redecorated my room; I chose the curtains and bedspread, and a new carpet. Once a month it gets a thorough spring clean, otherwise it's cleaned daily.'

We were told 'Staff still have no time to sit and chat with us. There seems enough staff' the staff do seem happier, laughing and joking. No long faces any more. I'm very content.' Another person said 'We now have staff for the residential floor.

Someone else told us 'There weren't enough staff in the past. I need help to get dressed and sometimes there hasn't been anyone available to help me until 10.30 in the morning. But now's there's enough staff.'

One person said 'The girls are very nice and they work very hard, but sometimes I have to wait up to 15 minutes before they come to help me.'

We asked one person if she had noticed any changes since our last visit. She said 'It seems a lot quieter now. Things seem more peaceful.' When we suggested that the buzzers did not seem as prominent as before she said 'Oh, that's right. I hadn't noticed, but you're right. They don't go on as much as before.'

People appeared happy to be at Birkin Lodge, and said they felt safe there. People feel free to spend their days how they like. One person told us 'I can to go to the lounges, but I'd rather do everything in here (his room)'. One person felt that everyone at the home is kind and she was happy to live there. One relative said 'My mother likes it here. She's been here six years.'

Activities are available, but have been limited recently due to staff illness. One person said 'Activities are a bit up and down at the moment ' sometimes they're cancelled.' We spoke to people who felt that staffing levels were stretched. One person who lived in the residential part of the home said 'One or two of the staff have been a bit difficult when I use the buzzer', and another said 'I have to wait a long time, but with no ill-effect so far, so mustn't grumble. I have wondered for some time if staff are a bit short'.

Another person told us 'once it took 20 minutes to answer to answer the buzzer' then they said 'what do you want? I'm busy'. I've had breakfast served to me at 10.30am sometimes!' One relative told us 'there's not a lot of continuity with the staff. People like to see the same face.' She did say 'the staff here are very nice.' Generally people feel that they are not involved with their care plans. One person told us 'They don't have time to do a care plan. Would they have time?' A relative told us they had been involved in their mother's care 'to a certain extent' I get to hear about what's going on through the residents meetings, but I don't hear anything specific about my mother's care.'

Overall, people felt the cleaning was adequate. One person said 'They're excellent about the cleaning.' Another person said 'I'd give the cleaning about 65 or 70%. The dust has been thick at times in this room.' One relative commented 'I don't know why they're decorating the lounges, they look fine. They need to do the bedrooms.'

These older reports are from our old approaches to inspection, including those from before CQC was created.

Archived: Birkin Lodge Care Home

All Inspections

22 February 2016

During a routine inspection

26 May 2015

During an inspection looking at part of the service

11 and 12 February 2015

During a routine inspection

11 September 2014

During a routine inspection

6 November 2013

During a routine inspection

20 August 2012

During a routine inspection

18 October 2011

During an inspection in response to concerns

During an inspection looking at part of the service

During an inspection in response to concerns

3 March 2011

During an inspection in response to concerns

Reports under our old system of regulation