What the CQC found at Birtley House Nursing Home

People were treated with compassion. Staff respected privacy and dignity, promoted independence and involved people in decisions about their care.

“People were treated with kindness and compassion by caring and dedicated staff and there was good interaction between staff and people.” from the report

There was a broad activities programme, including group activities, gardening, visitors and one-to-one support for people who spent time in their rooms.

“People had a range of activities that they could choose to be involved in.” from the report

Inspectors found that end of life care was sensitive and reflected people's wishes, including their faith and preferences about care.

“End of life care was provided sensitively and in line with people's needs and preferences.” from the report

Recruitment checks were completed, and inspectors found good hygiene practices, cleaning records and infection control procedures.

“People were protected against the spread of infection within the service.” from the report

Inspectors found examples where staff did not follow care instructions for falls, transfers, raised blood pressure, diabetes and wound care. This created a risk that people would not receive the protection or treatment they needed.

“Risks to people were identified and assessed, however, staff had not always followed the guidance in the risk assessments.” from the report

The home had not completed the required assessments and authorisations for covert medicines and bedrails. Staff could not explain how the Mental Capacity Act should be applied.

“Consent had not been obtained in line with the Mental Capacity Act 2005.” from the report

Several staff records showed long gaps in supervision and appraisal. This meant staff did not have regular opportunities to discuss their performance, roles or training needs.

“People were being supported by staff who had not had regular supervision. (One to one meetings) with their line manager.” from the report

Care plans did not always explain people's life histories or how to meet all their personal care needs. The provider had recognised this and started an action plan.

“People had not always received care that was personalised to their needs.” from the report

Audits had not identified several of the problems found by inspectors. There was also no registered manager in post at the time of the inspection.

“The service and quality audits undertaken were not robust and issues we found had not been identified.” from the report

The layout was on three floors and there were not enough signs to help people find rooms and communal areas. Inspectors recommended adapting the environment.

“There were not many signs up to show people the way to their rooms; this made it a little difficult to navigate or find one's way.” from the report