CQC report explained · a residential care home
What the CQC found at Birkinshaw Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were safe and protected from avoidable harm. Medicines, infection control, staffing, safeguarding and safety checks had improved, although some risk assessments and evacuation plans needed updating.
- Effective?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found that management and staff morale had improved and that audits, meetings and partnership working were in place. Some records and follow-up actions were not consistently completed.
What inspectors found, February 2023
Rated Good; inspectors found safe care and major improvements, but some records and risk assessments still needed attention.
This was an unannounced focused inspection on 30 and 31 January 2023. One inspector spoke with people, relatives, staff, managers and a health professional. The inspector reviewed four care plans, medicine records, audits and other documents.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicines management, good infection control and appropriate safeguarding. People and relatives said care felt safe. Management and staff morale had improved significantly.
Some care risk assessments did not clearly explain what staff should do. Daily records, some audit records and some monthly care reviews were not always complete or person-centred. The provider was no longer in breach of the regulations found at the previous inspection, but CQC recommended improvements to record keeping.
Safe care
People and relatives told inspectors they felt safe and well cared for. Safeguarding concerns were reported and investigated.
“People and relatives told us they felt care at the home was safe and they were well cared for by staff.” from the report
Medicines
Medicine checks were regular, records were up to date and staff competency was checked. Controlled medicines were stored safely.
“Regular checks were undertaken on medicines to ensure documentation was up to date and remaining medicine totals tallied with those given.” from the report
Cleanliness and infection control
The home was clean and tidy. Domestic staffing had increased and infection control audits were being completed.
“The home was clean and tidy and the number of domestic staff on duty had increased.” from the report
Improved activities and mealtimes
The provider had acted on recommendations from the previous inspection. Activities had improved and mealtimes were appropriate to people's needs.
“Activities had improved and were praised by people, relatives and staff.” from the report
Improved leadership
People, relatives and staff reported significant improvements in how the home was managed. The provider had introduced more audits and checks.
“The provider and registered manager had instigated a range of audits and checks to promote quality and safety in the home.” from the report
Incomplete care records
needs fixingSome daily records were not consistently completed. Monthly care reviews did not always focus enough on the individual person's needs and wishes.
“Some daily records were not always consistently completed, although staff had a good understanding of people's day to day needs.” from the report
Risk assessments need more detail
needs fixingSome care risk assessments did not clearly explain the action staff should take to reduce risks. A small number of personal evacuation plans also needed updating.
“People's care plans contained risk assessments related to their care. It was not always immediately clear what action staff should take to mitigate some of these risks.” from the report
Use of agency staff
needs fixingThere was a high use of agency staff to maintain staffing levels. People and relatives said this could sometimes affect care, although the provider tried to use familiar agency workers.
“There was high use of agency staff to maintain levels. People and relatives told us this could sometimes effect care, although the provider looked to ensure familiar care staff worked at the home.” from the report
Follow-up of checks
minorSome actions from audits were not followed up consistently. The provider also needed to improve how it looked for patterns and causes in accidents and falls.
“There was some evidence that actions were followed up although it was not consistent.” from the report
- 01How do you make sure each risk assessment clearly tells staff what action to take?
- 02What are you doing to reduce the effect of agency staff on continuity of care?
- 03How will you make sure daily records, audit records and monthly care reviews are completed consistently?
- 04How do you review accidents and falls to identify patterns and prevent them happening again?
- 05How will you maintain the improvements to activities and mealtimes?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 17 February 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, August 2022
Rated Requires Improvement; inspectors found kind and personalised care, but medicines, safety checks and management oversight were not reliable enough.
This was an unannounced inspection on 29 and 30 March 2022. Inspectors spoke with people, relatives and staff, reviewed care and medicines records, and looked at recruitment and management systems. They also checked infection prevention and control.
The home was rated Good for Effective, Caring and Responsive. People were treated kindly, involved in decisions and supported with individual care plans. Staff worked with health professionals, although activities did not always happen as planned and some food and drink records were not accurate.
The home was rated Requires Improvement for Safe and Well-led. Medicines records did not always match stock, some safety risks had not been fully assessed, and parts of the building were dirty or smelly. The provider had not found all these problems through its own checks.
The report found three legal breaches. These concerned safe care and treatment, duty of candour, and good governance. The provider took some action during and after the inspection, and CQC asked for an action plan and said it would monitor progress.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff treating people with dignity and supporting their independence.
“Staff interacted positively with people and worked in respectful ways to ensure people's dignity was maintained.” from the report
Personalised care planning
Care plans contained detailed information about people’s lives, preferences and dislikes. People were involved in decisions about their care.
“Care plans were individualised and contained detailed information about people's life histories and their likes and dislikes.” from the report
Safeguarding arrangements
The home had a safeguarding system, and staff raised no concerns about safeguarding practice. Relatives said people were safe.
“The provider had a safeguarding system in place. Staff raised no concerns about safeguarding practices in the home.” from the report
Working with professionals
Staff worked with health and social care professionals to help meet people’s health needs. End of life support involved an external care team.
“Staff liaised with health and social care professionals to help ensure people's health needs were met.” from the report
Medicines records
seriousAdministration records did not always match the remaining medicine stock. Inspectors could not be sure that medicines had always been given as prescribed.
“Medicines administration records which had been signed by staff did not always match with remaining stock counts of medicines.” from the report
Environmental safety and cleanliness
seriousSome risks had not been fully assessed. Toiletries and a hot kettle were accessible to people living with dementia, and some areas were dirty or smelly.
“Some toiletries and topical creams had been left in communal areas which people living with dementia could access and ingest.” from the report
Management checks
seriousThe home’s audits did not always identify problems, and action was not always taken when issues were found. This led to a legal breach for good governance.
“Where audits had identified shortfalls, action had not always been taken to implement improvements.” from the report
Activities and food records
needs fixingActivities were sometimes cancelled when activity staff covered care shifts. Records of what people ate and drank did not always accurately show their intake.
“Social activities did not always take place as planned.” from the report
- 01What changes have been made to check that medicines administration records match stock counts every time?
- 02How are environmental risks for people living with dementia now assessed and checked?
- 03What evidence can you show that quality audits identify problems and that improvements are completed?
- 04How will you make sure activities continue when activity staff are needed to cover care shifts?
- 05How are food and drink records checked to ensure they accurately reflect what each person has consumed?
This was an unannounced first inspection of the newly registered service covering all five key questions and infection prevention and control; the previous provider had been rated Inadequate in July 2021. This explanation was written from the published report of 10 August 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 Birkinshaw Manor
7 rated inspections over 5 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- November 2021InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2021Inspected but not ratedSafe: Inspected but not rated
- September 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- March 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- July 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021
Registered with the Care Quality Commission on 9 November 2021.
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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23 live-in carers within about an hour of Northumberland
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Most charge £950 to £1,190 a week. 20 can care for a couple. 11 years' experience on average.
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