Archived: Birdsgrove Nursing Home

Updated 29 December 2016

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.

The inspection was carried out by two inspectors on 10, 11 and 15 August 2016 and a specialist professional advisor on 11 August 2016. A specialist professional advisor is someone who has a specialist knowledge and experience in the service being inspected. The inspection was unannounced and it was a comprehensive inspection.

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This 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. Due to technical problems a PIR was not available and we took this into account when we inspected the service and made the judgements in this report.

Prior to the inspection, we reviewed the information we held about the service. We looked at statutory notifications that had been submitted by the service. Statutory notifications include information about important events which the registered provider is required to send us by law. We contacted the local authority commissioners to obtain feedback from them about the service. We looked at information received about the service from other people and stakeholders and we reviewed previous inspection reports.

During the inspection we spoke with 16 members of staff, including the manager, the nominated individual, two registered nurses, eight care staff, the activity coordinator, a member of the kitchen staff, a laundry assistant and a maintenance worker. We spoke with five people who use the service and six relatives and visitors.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us We watched a medicine round and attended a staff handover. We spent time observing activities in the communal areas of the service.

We reviewed six care plans and associated records including medicine administration records. We examined a sample of other records relating to the management of the service including staff training and supervision records, complaints, accident and incident reports, surveys and various monitoring and audit tools. We looked at the staff files for six staff and checked the recruitment records for the three most recently recruited staff members. We also reviewed documents relating to health and safety, for example, servicing certificates for equipment and risk assessments for fire and legionella.

Updated 29 December 2016

The inspection took place on10,11 and 15 August 2016 and was unannounced.

Birdsgrove Nursing Home is a care home with nursing. It is registered to provide accommodation and nursing care for up to 87 people. The Care Quality Commission (CQC) has placed a restriction on admissions to the service and at the time of this inspection 15 people were living at Birdsgrove Nursing Home. Following the last inspection the service was rated as Inadequate and placed into special measures. This inspection found there had been insufficient improvement to take the service out of special measures. CQC is now considering the appropriate regulatory response.

Some of the people using the service are living with dementia while others require assistance due to age or frailty. The service is arranged in three units. At the present time the unit in the oldest part of the service is not used by people living at the service. However, staff access this part of the premises for maintenance and storage purposes.

The service is required to have a registered manager. 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 time of the inspection the service did not have a registered manager.

The service had been without a registered manager since September 2015. Since then there had been staff appointed to manage the service but they had not registered with CQC. The current manager was appointed to the service in November 2015 and had submitted their application to register with CQC in July 2016. The current manager was present and assisted during the inspection.

We last inspected the service on 30 November and 1, 2 and 4 December 2015. At that inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found some improvements have been made however, a number of concerns remained evident.

A number of fire safety issues were identified which led to a referral to the fire safety officer. These included a fire risk assessment which made no reference to how less able people or people using wheelchairs would be managed safely if the premises need to be fully evacuated. Emergency lights did not always work or were dimly lit resulting in poor levels of lighting and a potential risk to those people with visual impairment or dementia. Final fire exit doors with energised magnets installed did not release when the fire alarms were activated and staff were not aware of how to override this to operate the doors manually. In addition, staff were not clear on the actions expected of them in a fire emergency or who the fire marshals were.

Other issues relating to the safety of the premises were identified and included the lack of a detailed risk assessment relating to the control of infection. It was therefore unclear how issues relating to storage, equipment cleaning, floor cleaning, utility areas and clinical hand washing facilities were managed and monitored. Areas of the service were found to be unclean with a build-up of dust, grease and grime. Mould was found growing across carpets and on tiles and bath sealant. Appropriate hand washing facilities and equipment were not always available and we could not be sure that staff understood the colour coding systems of cleaning equipment for preventing the spread of infection. Unlabelled substances and out of date supplies presented further risks to people using the service and staff.

Staff had identified a toilet leak and reported it to the manager and maintenance worker. However, the manager’s health and safety checks had failed to identify this as a potential slips/falls risk to people using the affected bathroom. It was not until inspectors indicated the risk of someone slipping and falling that action was taken to put the area out of use.

People’s personal information was not always kept confidential or secure. There was a risk personal records may be accessed by unauthorised personnel.

Staff were aware of their responsibilities with regard to safeguarding people. However, they were not all aware of the whistleblowing policy and who to contact outside the organisation if they needed to.

Medicines were ordered, administered and disposed of safely. Most storage was in line with guidelines. However, we found some creams stored in a cupboard where the temperature was not monitored, resulting in a risk of them becoming inactive or dangerous for use.

There were sufficient staff with appropriate skills to meet people’s needs. Staff had been recruited using effective recruitment procedures.

People’s right to make decisions was protected. When people could not make decisions for themselves appropriate best interests meeting were held. Staff sought consent from people before assisting them.

Staff received support in the form of meetings, appraisals and training which they considered sufficient to do their job effectively. People’s nutrition was monitored when necessary and people had sufficient to eat and drink. Their healthcare needs were met.

Some adaptations such as the use of memory boxes and coloured toilet seats had been made to the premises to meet the needs of people living with dementia, however, these were limited. Parts of the premises were in poor condition and needed attention.

Staff treated people with kindness, compassion and respect. They knew people well and provided privacy and dignity. People had the opportunity to plan the care they would like at the end of their lives.

Care plans reflected people’s needs and were regularly reviewed and updated. Staff were responsive to people’s needs and care was provided mostly in a person centred way. However, there were some examples of practice we could not be sure promoted people’s personal choice.

Activities were under review by the new activity co-ordinator who planned to include more personalised activities into the programme.

Audits were carried out but did not always identify areas where action was needed. We found the provider was reactive to issues raised but not proactive in identifying concerns and taking action to ensure the service was a safe place for people to live in and for staff to work in.

People, relatives and staff spoke highly of the manager who they felt was approachable and supportive. The manager had created an open culture in the service which had led to good team working and a positive attitude in the staff team.