CQC report explained · a nursing home
What the CQC found at Staveley Birkleas Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Risks were generally assessed and managed, staffing had improved and medicines were mostly managed safely. Inspectors found some care records, incident records and topical medicines records were not consistently complete, and wanted evidence that safety improvements would last.
- Effective?
- Good
- Staff had relevant training and support. People's nutrition and healthcare needs were monitored, and the home worked with health professionals.
- Caring?
- Good
- People and relatives gave very positive feedback. Inspectors saw kind, respectful care and staff supporting people's dignity, communication and independence.
- Responsive?
- Good
- Care plans generally reflected people's preferences and needs. People had varied activities, their communication and cultural needs were considered, and complaints were investigated and used to make changes.
- Well-led?
- Good
- Management systems and audits had helped improve the home. People, relatives and staff said the home had improved, although there was not a registered manager in place at the inspection.
What inspectors found, March 2019
Staveley Birkleas Nursing Home was rated Good overall, but Safe required improvement because inspectors wanted proof that improvements would last.
This was an unannounced comprehensive inspection on 22 January 2019. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care files, medicines records, staff rotas and incident records.
The overall rating was Good. Effective, Caring, Responsive and Well-led were all rated Good. Safe was rated Requires Improvement. Inspectors found that safety had improved since the previous inspection, when Safe was rated Inadequate and the home breached two regulations.
People said they felt safe and received kind care. Inspectors found enough staff, safer recruitment, suitable training, good food and access to healthcare. They also found some care records, incident details and topical medicines records needed more consistent attention.
The home was no longer in breach of the regulations identified at the previous inspection. However, inspectors said they needed evidence that safe practice could be sustained over time. There was no registered manager in place, although a manager had been appointed and was going through the registration assessment process.
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff listening to people, supporting their choices and protecting their privacy and dignity.
“People said staff treated them with kindness and compassion.” from the report
Improved staffing
Inspectors found enough staff to provide prompt care, including one-to-one support. Agency staff use had also reduced after new nursing staff were recruited.
“We observed throughout the inspection that staff were available and call bells were answered promptly.” from the report
Training and healthcare
The home provided a range of training, including specialist training for people's individual needs. Staff worked with health professionals, including regular GP visits and physiotherapy support.
“The service worked with external health professionals for example the epilepsy nurse to help ensure staff had the skills to meet people's individual needs.” from the report
Activities and personal choice
People had daily activities inside and outside the home, including trips and exercise. The home also considered people's cultural, religious, communication and language needs.
“People had access to a very good range of activities.” from the report
Management improvements
New management systems, audits and meetings had helped improve the service since the previous inspection. People, relatives and staff gave positive feedback about these changes.
“Systems put in place by the new manager had led to an improvement to the overall quality of the service.” from the report
Safety improvements needed to last
needs fixingSafe was rated Requires Improvement because inspectors were not yet fully assured that the improvements were consistent and could be sustained over time.
“These would need to be sustained before we were assured that the service was consistently safe.” from the report
Some care records were incomplete
needs fixingOne person's care plans did not consistently reflect their needs, and the person had not been weighed since admission. The manager acted immediately after inspectors raised this.
“However, we found one person's care records needed updating as care plans did not consistently reflect people's needs.” from the report
Medicines records
needs fixingMedicines were generally managed safely, but some records for topical medicines such as creams were not fully completed.
“Some topical medicine administration records we looked at were not fully completed.” from the report
Staff knowledge and incident records
needs fixingTwo staff members were not familiar with one person's falls prevention equipment. Some incident records also needed more detail to support thorough investigation.
“Whilst most staff were familiar with people's equipment and risks, two staff we spoke with were not familiar with the falls prevention equipment one person had in place.” from the report
- 01What checks now show that the improvements in safety have continued since the inspection?
- 02How do you make sure topical medicines, such as creams, are recorded every time?
- 03How are care plans checked so they always reflect each person's current needs and risks?
- 04How do you make sure every staff member understands the equipment and falls prevention measures for each person?
- 05Who is currently managing the home, and has the registered manager application been completed?
This was an unannounced comprehensive inspection covering all five key questions, with the previous Safe rating having been Inadequate. This explanation was written from the published report of 1 March 2019 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 2018
Rated Requires Improvement, with Safe rated Inadequate because inspectors found serious gaps in risk management, medicines and support hours.
This was an unannounced focused inspection after the CQC received safeguarding and other concerns. Inspectors looked mainly at whether people were safe and whether the home was well led. They reviewed care files, medicine records, staff rotas and incident forms, and spoke with people and staff.
Inspectors found that risks were not always properly assessed or recorded. Care plans and risk assessments were sometimes missing or out of date. There were also gaps in guidance for giving medicines when needed, and some people did not receive all their contracted one-to-one support hours.
The home had improved its management structure by adding clinical leads and shift managers. However, inspectors found that these changes had not yet improved care practice enough. The home remained in breach of three regulations, and the overall rating stayed Requires Improvement. The Safe rating was Inadequate and Well-led was Requires Improvement.
Improved management structure
The home had added clinical leads and shift managers. Inspectors said this gave some assurance about the future direction of the home, although the changes had not yet improved practice enough.
“We were encouraged that the service now had a complete management structure with the registered manager now supported by three clinical leads and shift managers.” from the report
Safeguarding response
The manager understood how to report safeguarding concerns. Inspectors saw that action, including disciplinary processes, had been taken when safeguarding incidents occurred.
“The registered manager demonstrated they understood how to report safeguarding concerns to the local authority and Care Quality Commission.” from the report
Some epilepsy care plans updated
Care plans for people living with epilepsy had been reviewed with specialist input. These plans included actions for staff to take in an emergency.
“This ensured all of these specific plans were up to date and detailed actions staff needed to take, for example, in an emergency situation.” from the report
More nurses on duty
Nurse staffing levels had improved since the previous inspection, with three nurses consistently on duty and clinical leads in place.
“Since the last inspection we found improvements had been made to nurse staffing levels with three nurses now consistently on duty and clinical leads in place.” from the report
Risks and care plans
seriousSome risks were not properly assessed or acted on. Care plans were missing, incomplete or not updated after incidents, including falls and changes in people's health.
“Risks to people's health and safety were not properly assessed.” from the report
Medicines guidance
seriousThere was not enough written guidance for staff giving medicines when needed. Inspectors found an example where pain relief had not been given after a person reported pain.
“There was a lack of protocols and information available for staff to help ensure 'as required' medicines were given consistently and appropriately.” from the report
Missed one-to-one support
seriousSome people did not receive the one-to-one hours set out in their contracts. This support was intended to provide companionship, activity and reduce distress.
“However, we found people were not always been provided with their contracted one to one support hours to provide them with interaction, stimulation and minimise distress.” from the report
Weak checks and records
needs fixingThe home did not have effective audits of care and records. Documentation was sometimes incomplete or inaccurate, making it difficult to know whether care and risks were being properly monitored.
“At the time of the inspection there was a lack of clinical governance, with no audits of people's care and support or care records taking place.” from the report
- 01What has been done to make sure every person's risk assessment and care plan is complete and updated after falls, incidents or changes in health?
- 02How are 'as required' medicines now supported by clear protocols, and how do you check that pain relief and other medicines are given appropriately?
- 03How do you make sure each person receives all of their contracted one-to-one support hours, including when staff are off sick?
- 04What regular audits are now being completed on care records, medicines and risk management, and who checks the results?
- 05How are decisions about equipment such as sensor mats discussed with the person or their representative and recorded?
This was an unannounced focused inspection of Safe and Well-led only; the report says the other three questions were not assessed. This explanation was written from the published report of 21 July 2018 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 Staveley Birkleas Nursing Home
4 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Staveley Birkleas Nursing Home →
- July 2018Requires improvementstayed Requires improvementSafe: InadequateWell-led: Requires improvement
Read what inspectors found at Staveley Birkleas Nursing Home →
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 December 2010.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
99 live-in carers within about an hour of Bradford
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 £1,250 a week. 87 can care for a couple. 12 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“She understands the needs of an elderly person in the early stages of dementia and has treated my mother with great kindness and skill.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.