CQC report explained · a residential care home
What the CQC found at Birkdale Village Care 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
- Inspectors were assured that infection risks were being managed, including PPE, testing, cleaning, visits and safe admissions. The provider also said it had measures to reduce the effect of COVID-19-related staffing pressures.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2022
Birkdale Village Care Home was inspected but not rated; inspectors found good infection prevention and control during the COVID-19 review.
This was an announced, targeted inspection on 3 February 2022. Inspectors looked at infection prevention and control, and asked about staffing pressures linked to COVID-19.
Inspectors found the home clean and hygienic. They found enough personal protective equipment, regular testing, an up-to-date infection control policy and safe arrangements for visits.
The home was inspected but not rated. Only infection prevention and control was reviewed, so this report does not give ratings for the other areas of care.
Clean environment
Inspectors found the home visibly clean and hygienic, with regular cleaning arrangements.
“The home was visibly clean and hygienic with regular cleaning schedules in place.” from the report
Infection controls
The home had an up-to-date infection prevention and control policy and a good supply of PPE. Staff were observed following PPE guidance.
“There was a good supply of PPE available throughout the home. Staff followed guidance around the use of PPE.” from the report
Safe visiting
The manager made sure relatives and friends could visit in line with government guidance.
“The manager made sure that visits from friends and relatives were facilitated safely.” from the report
Testing and monitoring
Residents and staff were tested regularly. The manager also carried out checks on hand hygiene and PPE use.
“Staff and people living at the home tested regularly for COVID-19 in line with guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing any staffing pressures caused by illness or COVID-19?
- 02How often are staff and residents currently tested when there is an infection risk?
- 03How do you check that staff use PPE and follow hand hygiene procedures?
- 04How are visits from relatives arranged if there is an outbreak or other infection risk?
This was a targeted inspection of infection prevention and control, with questions about COVID-19-related staffing pressures; it was not a full inspection and the service was not rated. This explanation was written from the published report of 11 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.
What inspectors found, July 2021
Rated Requires Improvement; inspectors found caring staff and good infection controls, but medicines and oversight were not safe enough.
This was an unannounced focused inspection on 1 April and 14 May 2021. Inspectors looked at Safe and Well-led, following concerns about infection control and how the service was managed. They spoke with people, staff, a visiting professional and relatives, and checked care records, staff files, medicines records and safety documents.
People appeared well cared for, and staff were described as caring and familiar with residents. There were enough staff, and infection control arrangements were judged reassuring. However, medicines were not always managed safely, some staff checks were out of date, and systems for safeguarding, risk reviews, incidents and quality checks were not strong enough.
The overall rating changed from Good at the previous inspection in July 2019 to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The report says there was no evidence that anyone had been harmed, but it found potential risks and three legal breaches.
Caring staff
Staff were described as caring, positive and familiar with the people living in the home.
“There was a caring and positive culture amongst staff at the service.” from the report
Enough staff
Inspectors found staffing levels were sufficient to keep people safe and meet their needs.
“There were enough staff to keep people safe and meet their needs.” from the report
Infection control
Inspectors were assured about infection prevention measures, including visitors, protective equipment, testing and outbreak planning.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Working with professionals
The home worked with outside professionals and responded positively to feedback about people's care.
“The service worked well with external professionals such as district nurses to achieve good outcomes for people.” from the report
Medicines
seriousMedicines were not always given safely or as prescribed. The medicines policy was out of date, audits had not been completed, and some night staff were signing before medicines were given.
“People did not always receive their medicines safely or as prescribed.” from the report
Staff recruitment checks
seriousChecks for existing staff were not up to date, so managers did not always have current assurance that staff were suitable.
“The service did not have up to date disclosure and barring checks for existing staff.” from the report
Management oversight
seriousQuality checks did not reliably identify problems with medicines, recruitment or safeguarding. The provider also lacked effective systems for learning from accidents, incidents and complaints.
“The provider failed to operate effective systems for checking on the quality and safety of the service.” from the report
Safeguarding systems
needs fixingFormal systems for identifying, recording and monitoring possible abuse were not robust, and staff training records and knowledge had gaps.
“There was a lack of effective systems in place to identify, record and monitor safeguarding concerns, should they arise, to safeguard people from the risk of abuse.” from the report
Risk reviews and incidents
needs fixingRisk assessments were in place, but there was not enough evidence that they were regularly reviewed. Incident recording and audits were also not effective.
“There was a lack of evidence to show ongoing monitoring of risk.” from the report
- 01What checks have now been completed for all existing staff, including disclosure and barring checks?
- 02How do you now make sure medicines are given and recorded safely on every night shift?
- 03What system do you use to audit medicines, incidents, complaints and safeguarding concerns?
- 04How often are residents' risk assessments reviewed and updated?
- 05Has the manager applied to become registered with CQC, and what progress has been made on the action plan?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 14 July 2021 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 Village Care Home
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- July 2021Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
- January 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2010
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 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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38 live-in carers within about an hour of Sefton
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,270 a week. 34 can care for a couple. 11 years' experience on average.
“He developed a close affinity with Terence, spending time talking with him before he retired to bed and looking after his needs during the night.”
“It was clear that she genuinely cared and her warm approach really helped put our minds at ease.”
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