• Care Home
  • Care home

Birkdale Village Care Home

Overall: Requires improvement read more about inspection ratings

20 Crescent Road, Birkdale, Southport, Merseyside, PR8 4SR (01704) 564801

Provided and run by:
SBS-Services Limited

All Inspections

3 February 2022

During an inspection looking at part of the service

Birkdale Village Care Home is a residential home providing personal care for people aged 60 and over. There are 20 rooms available with 14 residents living there currently. Birkdale Village is one building, across three floors. All floors are accessible via a lift. There is a garden and conservatory available for people and their visitors to use.

We found the following examples of good practice.

The home was visibly clean and hygienic with regular cleaning schedules in place.

There was an up to date infection prevention and control policy.

There was a good supply of PPE available throughout the home. Staff followed guidance around the use of PPE.

The manager completed spot checks to make sure staff were following guidance around hand hygiene and use of PPE.

Staff and people living at the home tested regularly for COVID-19 in line with guidance.

The manager made sure that visits from friends and relatives were facilitated safely.

1 April 2021

During an inspection looking at part of the service

About the service

Birkdale Village Care Home is a residential home providing personal care for people aged 60 and over. There are 19 rooms available with 16 residents living there currently. Birkdale Village is one building, across three floors. All floors are accessible via a lift.

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

People appeared well cared for and looked after. There was a caring and positive culture amongst staff at the service. However, the systems and processes underpinning people’s care were not always safe and robust.

Although we found no evidence that people had been harmed as a result, we identified several areas that put people’s health and safety at potential risk.

The provider did not have an effective system in place to safely manage the administration of people’s medicines. The provider did not have an adequate system in place to learn lessons if mistakes were made. We have made a recommendation about updating some risk assessments, as well as incident recording and audits.

There was a ‘family’ type feel and many of the staff had worked at the service for several years, meaning they knew the people that lived there well. However, although we found no evidence of safeguarding concerns during our inspection, there was a lack of formal systems and processes in place to protect people from the risk of abuse. We have made a recommendation regarding safeguarding processes.

Governance systems were not always effective and needed to be updated, to ensure opportunities were not missed to improve the service. However, the provider did respond positively and effectively to feedback from other professionals, to make improvements to people’s care.

People were protected from the risk of spread of infection especially around COVID-19. At the time of inspection there had been no recorded cases in the service throughout the pandemic. People and relatives said they felt safe and there were enough staff to safely meet their needs.

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: The last rating for this service was good (July 2019).

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 received concerns in relation to infection and prevention control, and the governance of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

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

You can see what action we have asked the provider to take at the end of this full report.

The provider has taken some actions to mitigate the risks.

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

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.

We have identified breaches in relation to the management of medicines, staff recruitment and monitoring the quality and safety of the service.

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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

25 June 2019

During a routine inspection

About the service

Shandon House is a residential care home providing personal and nursing care to 14 people aged 65 and over at the time of the inspection. The service can support up to 20 people in one adapted building over different floors.

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

We read in one relative’s feedback, “The residents and staff are like a family and family visitors seem to be treated just the same.” This was echoed by everyone we spoke with during the inspection. Visiting health professionals told us how much they enjoyed coming to Shandon House. They praised the positive, effective relationship they had with the service to look after people’s health and wellbeing.

We found issues with regards to health and safety checks and medicines management that needed to be improved to protect people robustly. We made recommendations regarding these matters. However, people told us they felt safe living at Shandon House. People said the staff treated them with respect and kindness and we observed this. We saw that people had developed friendships with others living at the home and cared for each other.

The provider had recognised that the service needed refurbishment and redecorations were ongoing. A variety of activities were still on offer, including regular visits by entertainers, although there had been fewer trips out. People were offered regular drinks throughout the day and a variety of food to choose from. There were enough staff to meet people’s needs and staff knew people well. The registered manager was developing person-centred plans and how they involved people and their families. Staff felt supported and involved in the development and delivery of the service. The well-respected registered manager led a service culture that promoted equality and diversity.

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

The last rating for this service was good (published 5 January 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

5 December 2016

During a routine inspection

This inspection took place on 5 December 2016 and was unannounced. At the last inspection on 8 October 2015 we found breaches of the HSCA 2008 (Regulated Activities) Regulations 2014, in Regulation 12, Safe care and management and Regulation 15, Premises and equipment. At this inspection we found that improvements had been made in all areas to meet the relevant requirements.

Shandon House is a care home providing accommodation and personal care for up to 20 older people. It is a converted house with gardens and seating areas at the side and front of the building. There is a ramp at the main entrance to assist people with limited mobility. Bedrooms, bathrooms and lounges are situated on the ground and upper floors. Some bedrooms have ensuite facilities. There were 17 people living in the home 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.

Medicines were managed safely in the home.

Risk assessments had been undertaken to support people safely and in accordance with their individual needs.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported.

Safety checks of the environment and equipment were completed regularly.

There were enough staff on duty to provide care and support to people living in the home.

The provider had robust recruitment procedures in place to ensure staff were suitable to work with vulnerable adults.

Staff worked in partnership with health and social care professionals to make sure people received the care and support they needed.

Staff were trained to ensure that they had the appropriate skills and knowledge to meet people’s needs. They were well supported by the registered manager.

Staff sought the consent of people before providing care and support. The home followed the principles of the Mental Capacity Act (2005) for people who lacked mental capacity to make their own decisions.

People told us they liked the food and were able to choose what they wanted to eat.

People told us the staff had a good understanding of their care needs and people’s individual needs and preferences were respected by staff.

People at the home told us they were listened to and their views were taken into account when deciding how to spend their day.

Care plans provided information to inform staff about people's support needs, routines and preferences.

People told us staff were kind, polite and maintained their privacy and dignity. We observed positive interaction between the staff and people they supported.

A programme of activities was available for people living at the home to participate in.

A process for managing complaints was in place. People we spoke with knew how to raise a concern or make a complaint.

Feedback we received from people, relatives and staff was complimentary regarding the registered manager’s leadership and management of the home.

Staff told us there was an open and transparent culture in the home.

Systems and processes were in place to assess, monitor and improve the safety and quality of the service.

People living in the home and relatives told us they were able to share their views and were able to provide feedback about the service.

8 & 12 October 2015

During a routine inspection

Shandon House is a care home providing personal care. It can accommodate 20 older people. The home is owned by SBS Care Homes Ltd.

This was an unannounced inspection which took place over two days on 8 &12 October 2015.

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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found the service was not always safe. There were some good monitoring / checking systems in place to ensure the home was maintained safely but we found that people had unnecessarily been exposed to a risk because some environmental hazards had not been effectively monitored. These were with respect to monitoring of infection control and fire safety in the home.

Medicines were administered safely. Medication administration records [MARs] were completed in line with the home’s policies and good practice guidance. We recommended some review of the medication policy and development of a medication audit tool.

Staff understood what abuse meant and knew the correct procedure to follow if they thought someone was being abused. People we spoke with told us they felt safe living at Shandon House and they were well supported.

There were enough staff on duty at all times to help ensure people were cared for in a safe manner. Staff had been checked when they were recruited to ensure they were suitable to work with vulnerable adults.

We looked at whether the home was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. We found examples of good practice in supporting people with decisions in their ‘best interest’. We discussed the need to extend the use of current good practice to more key decisions for people. The manager said this would be developed with further staff training.

People told us the meals were good and well presented. We observed and spoke with people enjoying lunch. We were told that there was choice available with meals.

We asked people if staff were polite, respectful and protected their privacy and dignity. We received positive responses. Our observations of care supported good practice.

There was some information available in the home for people. We discussed some key information such as the complaints process. We were sent an updated copy of the homes ‘Statement of Purpose’ which provided accessible information; for example, regarding the complaints procedure.

We found people and their relatives were involved in planning their care to help ensure it was more personalised and reflected their personal choices, preferences, likes and dislikes. We looked at the care record files for people who lived at the home. We found that care plans and records recorded of this information.

We found people were provided with social activities and were encouraged to participate in the daily life of the home.

We saw a complaints procedure was in place and people, including relatives, we spoke with were aware of how they could complain. We saw an example of one complaint that had been received and dealt with. This had been responded to appropriately.

The manager was able to evidence a series of quality assurance processes and audits carried out internally. We found some of these were not currently developed to ensure the most effective monitoring.

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

3 February 2014

During a routine inspection

We spoke with eight people about the service that they received. They told us they were happy with the way staff supported them and said the quality of the care was good.

Those we spoke with said the staff knew what support they required and did everything that was needed for them. One person told us, 'The care is very good. There's enough staff around when I need them.' Another person said, 'I've seen my GP a few times. The staff arrange things for me.'

People were very relaxed around staff and said they were listened to, so any concerns could be addressed. People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening

We spoke with staff. They told us they felt supported in their job. They told us there was good communication between different levels of staff. They felt there was always enough staff on duty to carry out the care needed. We asked people who used the service about the skills of the support workers. They told us the staff worked very hard and knew how to do their job. They felt staff were competent.

We looked at the system to manage complaints in the home. We found the complaints procedure was available to people. There were no complaints recorded for the service since our last inspection.

We looked at various records. These included care records and staff records. We found the records were up to date and held securely.

12 March 2013

During an inspection looking at part of the service

We observed part of the lunchtime medicines round and saw that patient support was offered where people needed help with taking their medicines. People choosing to self-administer medicines were supported to do so. One person we spoke with confirmed that they had everything they needed to safely manage their own medicines. Other medicines were administered by care workers who had completed certificated training in medicines handling. Regular medicines audits (checks) were completed by the manager but we noted that these were quite narrow and did not consider all aspects of medicines handling.

12 December 2012

During a routine inspection

We spoke with people about the service that they received. They

told us they were happy with the way staff supported them and the way they were cared for.

Those we spoke with said the staff knew what support they required and did everything that was needed for them. One person told us, 'It's OK here. The care is very good and that's the main thing.'

We spoke with three care staff. They told us they had received relevant training and they felt supported in their job and received supervision from their manager. We asked people who used the service about the skills of the care staff. They told us the staff worked very hard and knew how to do their job. They said staff were competent.

We spoke to people about the service they received with regards to their involvement in monitoring the quality of the service. They told us they had attended a recent meeting so that their views could be known. They said they were able to contact the manager if they ever had a problem with the service.

We looked at how medicines were managed and found that some improvements were needed to ensure these were monitored effectively.

27 September and 16 November 2010

During a routine inspection

We spoke with people living at Shandon House and asked their views specifically about their experiences of how the service involved them and kept them informed. All confirmed, that they felt like they were encouraged to express their views openly. They were of the opinion that these views were being taken into account by staff in the decision making for the care and treatment they received at Shandon House. People expressed the view that they felt like they were treated with respect and dignity.

Summary of our findings for the essential standards of quality and safety A number of residents reported that staff at the home regularly explained and discussed the care and treatments they would receive. People confirmed that their wishes were listened to, food choices in particular were discussed on a number of occasions. It was evident in the discussions with one resident with more complex dietary requirements, that the home provides choices of food and drinks for people to meet their diverse needs.

Comments included:

'The staff are good and they spend time and give the support I need'

'I get help when I need it. Staff are very good'

'The staff are good - very helpful and they find some time to talk'

For two of the people interviewed their family members were also present at the time of the visit, we observed that the family members were being made to feel welcome by staff. We saw a record of family involvement in a review of a person living in the home which was positive and comments included 'everything is working well.'

We spoke with one person who had daily visits from the district nurses to support health care needs. They told us that they felt well supported and that the staff at Shandon House liaised well on their behalf. Other people told us that the staff are very responsive and call out the doctor when needed. This shows attention to people's health care needs.

All of the people we spoke with said that they felt relaxed and able to approach staff. We observed staff interacting with people living at the home in a positive and supportive manner. Some residents were asked directly whether they felt 'safe' and they said that they did and that they felt staff would listen to any concerns and act on them. This shows staff uphold people's rights and they are kept safe.

Although generally very positive about staff and the care carried out we did collect some comments that the home was felt to be not always staffed adequately in terms of numbers. One person considers the home to be a 'bit short staffed at times mainly due to sudden illness of staff'. Some other comments supported this. The people concerned could not give any evidence as to how staff shortage affected their care however. This shows that currently staffing of the service is generally satisfactory although some people may get anxious about this at certain times.

People said that medication was well managed and that they were given some choice and independence in this. For example one person was managing her own medication and felt comfortable with this and felt well supported so was able to be more independent.

We spoke with people on the site visit and they told us that they felt staff listened to their concerns and they felt the manager and staff would act appropriately if needed. Nobody we spoke with had any concerns or complaints. We spoke with the manager as part of this review and there have been no complaints recorded internally. CQC have received no complaints about the service since the last inspection.