CQC report explained · a residential care home
What the CQC found at Birkdale Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Rated Inadequate and placed in special measures; inspectors found serious risks to safety, infection control, medicines and management.
The inspection was unannounced and took place on 20 June 2023. One inspector spoke with people, relatives and staff, and checked care records, medicines records, recruitment files and management checks.
Inspectors found people were at risk from unsafe furniture, hazardous substances, burns, falls, fire safety problems and possible infection. Medicines were not always given as prescribed. The home did have enough staff, followed recruitment checks and had arrangements to protect people from abuse.
The home’s checks did not identify or deal with these problems. Inspectors found breaches of Regulations 12 and 17. The overall rating fell from Good at the last inspection in 2019 to Inadequate. The home was placed in special measures.
Enough staff
Inspectors found enough staff were available to support people without unreasonable delays.
“People were supported by enough staff who were available to safely support them without any unreasonable delay.” from the report
Safeguarding
Staff had training on abuse and understood how to report concerns to the appropriate agencies.
“People were safe from the risks of abuse and ill treatment.” from the report
Mental capacity practice
Inspectors found the home was working within the Mental Capacity Act and used best-interest decisions when needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Open relationships
People, relatives and staff described management as accessible, supportive and open to views.
“All those we spoke with found they had a positive relationship with the management team who they found to be accessible and engaging.” from the report
Unsafe environment
seriousFurniture, hot surfaces, pipework, flooring and fire doors created risks of crushing injuries, burns, trips, falls and harm in a fire.
“People were at the risk of harm as the provider failed to ensure the physical environment was safe for people to live in.” from the report
Poor infection control
seriousInspectors found dirt, damaged surfaces, poorly stored food and no regular programme for cleaning high-frequency touch points. Visitors were not checked for infection symptoms when entering.
“We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Medicines not always safe
seriousTwo people’s records showed prescribed medicated creams had been missed. There was also no proper guidance for some medicines given when needed.
“Two peoples' records of medicine administration (MAR) showed their medicated creams were not given as prescribed.” from the report
Weak checks and learning
seriousThe provider did not properly review incidents or check that earlier concerns had been fixed. It also had not completed a legionella risk assessment.
“The provider did not effectively review all incidents, accidents or near misses to see what could be done differently to minimise the risk of reoccurrence.” from the report
Poor management oversight
seriousManagement checks failed to identify risks involving furniture, fire exits, food storage, medicines and infection control. This was a breach of the good governance regulation.
“The provider did not have effective quality monitoring systems to ensure people received good care.” from the report
- 01Which unsafe wardrobes, heavy items, radiators, pipework, flooring and fire doors have now been repaired or secured?
- 02How are hazardous substances, medicines and drinks thickener now stored so people cannot access them unsafely?
- 03What changes have been made to medicine checks, including records for medicated creams and guidance for medicines given when needed?
- 04What cleaning programme and infection checks are now in place, including checks on food storage and visitors entering the home?
- 05What action has been taken to complete the legionella assessment and make sure incidents lead to lasting improvements?
This was a focused inspection of Safe and Well-led, prompted partly by concerns about risks in the building; the other key question ratings carried over from the last inspection. This explanation was written from the published report of 13 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, February 2022
Inspected but not rated; inspectors found good COVID-19 infection controls, but some flooring was damaged.
This was an announced, targeted inspection on 24 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19.
Inspectors found good practice. Visitors were checked for vaccination evidence where required, PPE was available and used, and relatives were kept updated about visits. People and staff were tested regularly and had received COVID-19 vaccinations.
The home was assured on most infection control arrangements, including PPE, testing, safe admissions and managing outbreaks. However, some flooring was ripped and damaged, which could create an infection control concern. The provider later sent plans to replace it.
The service was inspected but not rated. This report gives no overall rating and does not rate the other four key questions.
Visitor checks
Visitors were checked for vaccination evidence where this applied. A visiting professional was refused entry when they could not provide the required evidence.
“Visitors were checked on arrival for proof of vaccination where it was applicable.” from the report
PPE and testing
Inspectors saw a plentiful supply of PPE and staff wearing it. People and staff were regularly tested and had received COVID-19 vaccinations.
“We saw there was a plentiful supply of PPE throughout the building and staff were observed to be wearing it at all times.” from the report
Keeping relatives informed
The manager kept relatives updated about changes, and visits were taking place in line with the guidance at the time.
“The manager kept relatives up to date with any changes and people were receiving visits from their relatives in line with the current guidance.” from the report
Damaged flooring
needs fixingSome flooring was ripped and compromised. Inspectors said this could create an infection control concern, although the provider later sent plans to replace it.
“We found that some flooring was ripped and compromised which could lead to an infection control concern.” from the report
- 01Has the ripped and compromised flooring now been replaced throughout the home?
- 02What infection control checks are being carried out while any flooring remains damaged?
- 03How are COVID-19-related staffing pressures being managed now?
- 04How are visitors checked for vaccination evidence or exemptions?
- 05How are people and staff being tested for COVID-19?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 10 February 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 Birkdale Residential Home
7 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- September 2023Inadequatecurrent ratingSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
- February 2022Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- June 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2018Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- November 2016Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Requires improvement
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2012
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 21 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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