CQC report explained · a nursing home
What the CQC found at Birdscroft Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were enough staff and medicines were managed safely, but some risk assessments lacked guidance, bed rail repairs were not followed up promptly and infection control practices were not always effective.
- Effective?
- Good
- Staff were suitably trained, people were supported with food, fluids and healthcare, and recommendations from healthcare professionals were followed. Records did not always show clearly how mental capacity and best-interest decisions had been made.
- Caring?
- Good
- People and relatives described staff as kind, respectful and caring. Inspectors observed calm interactions that promoted dignity, privacy, choice and independence.
- Responsive?
- Good
- Staff understood people's needs and preferences, and activities had improved. Some care plans still lacked enough detail about how particular needs should be supported.
- Well-led?
- Requires improvement
- The home had quality checks, but they did not consistently identify or act on risks involving care records, infection control, the environment and mental capacity decisions. This was a continuing breach of Regulation 17.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found kind and responsive care, but weaknesses in safety checks and quality oversight remained.
This was an unannounced follow-up inspection on 17 July 2023. Inspectors spoke with six people, four family members, five staff and healthcare professionals. They reviewed care and medicine records, staff files, incidents and quality checks.
The home had enough staff to meet people's care and safety needs, and medicines were managed safely. People were treated with kindness and dignity. Activities, communication, food and access to healthcare were also viewed positively.
However, some risk assessments and care plans lacked important detail. Inspectors found problems with infection control, the condition of some equipment and the way mental capacity decisions were recorded. The home's monitoring systems had not identified these issues.
The overall rating remained Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led remained Requires Improvement. The home had also been rated Requires Improvement at the previous inspection.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw warm, patient interactions that respected people's dignity and individuality.
“Throughout the inspection we observed staff to be warm, friendly and respectful.” from the report
Staff training and healthcare
Staff had suitable training and induction. People were referred to healthcare professionals appropriately, and staff followed the advice they received.
“Staff were suitably trained to meet people's needs.” from the report
Activities and engagement
The home had a regular activities programme shaped by people's preferences. People and relatives gave positive feedback about the activities and events.
“There was a regular and established programme of activities which met people's individual needs” from the report
Safe medicines management
Medicines were stored and administered safely by qualified nurses. Records explained gaps and included photographs and allergy information.
“Medicines were managed and stored safely.” from the report
Weak quality checks
seriousThe home's internal checks did not identify several problems found by inspectors. This meant risks were not consistently reduced or improvements sustained.
“The provider did not have a consistent approach to effective quality monitoring.” from the report
Infection control shortfalls
seriousInspectors found unpleasant odours, poor handwashing and laundry handling practices, and worn bed bumpers that were harder to clean. These findings created potential infection risks.
“It was identified during the site visit that staff were not following good practice guidance regarding handwashing and how linen was managed in the laundry area.” from the report
Incomplete risk and care records
needs fixingSome records did not explain clearly how staff should manage risks or support particular needs. Examples included distress, mobility, skin care and mental health-related behaviours.
“Some risk assessments lacked information for staff about ways in which those risks should be mitigated.” from the report
Mental capacity records
needs fixingCapacity assessments and best-interest decisions were not always recorded properly. Records sometimes gave conflicting information about whether people had capacity.
“Some decisions were recorded as best interest decisions.” from the report
Afternoon staffing time
needs fixingAlthough staffing was judged sufficient overall, reducing the afternoon care team from six to five left less time for social interaction and, according to one staff member, personal care.
“At other times, staff did not have time to engage on a social level with people.” from the report
- 01What specific actions are being taken to fix the infection control problems involving handwashing, laundry separation, odours and worn bed bumpers?
- 02How are you making sure every care plan and risk assessment gives staff clear instructions about managing risks?
- 03How are mental capacity assessments and best-interest decisions being recorded and checked?
- 04What has the dependency review decided about reducing afternoon staffing from six care staff to five?
- 05What progress has been made on the action plan required after the continuing Regulation 17 breach?
This was an unannounced follow-up inspection covering all five key questions, carried out to check action required after the previous inspection. This explanation was written from the published report of 1 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind staff and safe medicines, but serious shortfalls in staffing, restraint, activities and management oversight.
This was an unannounced inspection on 20 July 2022. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, staff files and management records, and checked infection control.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found too few staff at busy times, gaps in staff training, care records that were sometimes unclear, and too few meaningful activities. One person was subjected to restrictive practices without proper assessment or consent.
There were also positive findings. Staff were described as kind, medicines were managed safely, the home was clean, and people had access to health professionals. However, the overall rating means the service was not consistently safe or person-centred. The rating had fallen from Good at the previous inspection, published in January 2018.
Safe medicines
Medicines were stored, disposed of and recorded safely. Staff administering them were trained and assessed as competent.
“Medicines were stored and disposed of safely. Staff responsible for administering medicines kept accurate medicines records, had received training in medicines and were assessed as competent in the task.” from the report
Clean environment
Inspectors found the home clean and hygienic, with effective infection prevention and control systems.
“The home was clean and hygienic and staff maintained effective systems of infection prevention and control” from the report
Kind staff
Most people and relatives spoke positively about staff. Inspectors observed staff treating people kindly and respectfully.
“We observed staff approached people in a respectful and kind manner. They checked people had everything they needed and if there was anything else they needed.” from the report
Health support
People had access to health professionals, and wound care was described as comprehensive and well managed.
“Wound care plans were comprehensive and wound care was well managed.” from the report
Too few staff
seriousStaffing levels did not reflect people's changing needs. People experienced long waits for personal care and help with daily tasks.
“Failure to deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff was a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Use of restraint
seriousStaff used restrictive practices with one person without proper assessment, consideration of capacity or consent. Managers were not aware this was happening.
“The provider used restraint without consideration of how proportionate this was in relation to the risk of harm to one person, and without assessment of that person's needs or their capacity to consent.” from the report
Incomplete training
needs fixingTraining compliance was low in areas linked to people's rights, personalised care and behaviour support. Inspectors also observed poor practice in these areas.
“For example, MCA and DoLS was at 57%, person-centred care 54% and challenging behaviours 27% and we observed poor staff practice in these areas.” from the report
Few meaningful activities
seriousPeople often had little stimulation or one-to-one time. Planned activities did not always happen because care staff were used for other duties.
“We found a lack of meaningful activities were being provided for people. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Unclear care plans
needs fixingSome care plans contained conflicting information or did not explain people's needs, preferences and life histories well enough for staff to provide consistent care.
“People's care plans did not always hold accurate information about their care. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Fire safety concerns
seriousInspectors were not fully assured that evacuation arrangements were robust. The Fire and Rescue Service later found some people were at risk in a fire and made recommendations.
“Following their visit shortly after the inspection, the Fire and Rescue Service found some people were at risk in case of fire, and made certain recommendations.” from the report
- 01What are the current staffing levels on mornings, evenings and weekends, and how are they adjusted when people's needs change?
- 02What training have all staff completed on the Mental Capacity Act, person-centred care and managing behaviours that challenge?
- 03What safeguards are now in place to prevent restraint being used without a proper assessment, best-interests decision and consent?
- 04How are activities planned around each person's interests, and how do you check that planned activities and one-to-one time actually happen?
- 05How have conflicting care plans been corrected, and how are relatives involved when a person's needs or preferences change?
This was an unannounced inspection covering all five key questions, including infection prevention and control, the premises and the care provided. This explanation was written from the published report of 22 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Birdscroft Nursing Home
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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