Birnbeck House - Care Home Learning Disabilities

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

As part of this assessment, we looked at 4 quality statements for the key questions of Safe, safeguarding, safe and effective staffing, involving people to manage risks and medicines optimisation. The score for this area has been combined with scores based on the rating from the last inspection, which was good. The Safe key question has now been rated as requires improvement. We identified 5 breaches of the regulations safeguarding, person centred care, dignity and respect, safe care and treatment and staffing. Safeguarding concerns were not always identified, recorded, and reported. Risks to people were not always assessed, monitored, and managed to keep them safe. Medicines were not always safely managed. The provider had failed to ensure staff were trained to enable them to deliver safe and effective care and support to people. Person centred care was not always being provided and people were not always treated with dignity and respect. Safeguarding systems and processes were in place to help ensure people were protected from the risk of abuse and neglect. However safeguarding concerns were not always being identified or appropriate actions taken by staff or management. The interim manager discussed their plans to improve in this area. The service was working closely with the local authority at the time of our assessment. Improvements were required in identifying risk. Records evidenced not all staff had completed the necessary training required for their roles. Decisions made about people's care were not always made following the principles of the Mental Capacity Act (MCA). People’s medicines were not always given in the correct way. There had been changes to the management team of the service and there was currently no registered manager at the home, although an interim manager and senior management team were in place. Staff were supported and people using the service told us they felt safe.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us their loved ones were safe. When there had been safeguarding concerns, they had been informed and told of actions taken by the service to investigate the concerns. We heard “Oh yes, they keep them safe” and [person] “seems safe and happy”. Relatives were aware if people lacked capacity to make some decisions in line with The Mental Capacity Act 2005 (MCA). However, during our visits to the service, we observed several incidents of people experiencing poor care.

Staff knew how to report safeguarding concerns, they told us they were confident to raise any concerns they had relating to people’s care and support, and people were safe living at the service. Staff understood the principles of the Mental Capacity Act (MCA) and, where relevant to their role, had received training. They were able to explain how they apply the MCA principles in practice, including gaining consent to care. Staff told us they knew how to respect people's privacy. Staff told us they had completed safeguarding training and understood what constituted abuse. They said they were aware of the internal processes to follow to safeguard people in their care. However, during our inspection we found incidents of poor care which were not always being identified or reported by staff.

During our visits to the service, we observed several incidents of people experiencing poor care. People were not always supported by staff who had a good understanding of equality and diversity and how to treat someone with dignity and respect. We observed some people were left on their own for long periods of time without interaction from staff, except at mealtimes. We also observed people’s dignity not being protected whilst receiving support with personal care, and medication being administered not in line with specific guidance in place for the person. We were not assured people were receiving safe, person centred and dignified care or staff understood people's needs and were following their care plans.

Whilst the service was completing some mental capacity assessments and best interest decisions for people, these were not always decision specific and up to date. Some mental capacity assessments had not been completed, for example where people were being given their medication covertly there was not always the appropriate Mental Capacity Assessments, Best Interest Decisions and risk assessments in place to accompany this decision. The manager reviewed this during our assessment and acted promptly to address it. Deprivation of Liberty Safeguard (DoLS) referrals had been made for people where restrictions were in place. However, where people’s needs were changing, and additional restrictions were in place this had not always been shared within the referral to the local authority. The service was not always recording and reporting concerns. This meant the provider did not have effective oversight of what is happening in the service and could take action where needed. Some people at the service do not have capacity to consent to their care and are unable to raise concerns themselves. Whilst the service was reporting safeguarding concerns, there were some gaps in identifying incidents of poor care and potential safeguarding concerns. During our assessment we identified several safeguarding concerns and incidents of poor care which were not identified or reported by the service. We reported our safeguarding concerns to the local authority.

Relatives told us they were involved in solutions to support people to manage risks. One relative told us they raised concerns regarding the care of their relative and the service acted to improve. We heard from people’s advocates there had been some delays in making referrals to external health services, however the interim manager had identified this, and referrals had now been made. However, we were not assured people were receiving person centred care when they needed or wanted it.

People’s eating and drinking guidelines, including those people on modified diets, were being reviewed by the provider’s service improvement manager. We saw a document in the kitchen providing this information clearly to staff. The interim manager told us they are completing daily walk arounds that review meals being served to people and if the SALT guidance is being followed. Staff told us care plans contained the information they required to support people well. Staff did comment there might not always be enough staff and we observed people were left by themselves for periods of time throughout the day. Staff told us they knew the process to follow to record and report incidents and accidents. However during our inspection we found some incidents were not being identified or recorded. Positive behaviour interventions were not being observed and from reviewing records it was also not clear how incidents such as these were being recorded or what training staff had received to support people with this. Staff were able to confirm who they support with positive behaviour support; they confirmed incidents and accidents were recorded. However, while the service was receiving support from a positive behaviour support specialist from one person, the staff team had not been trained in this area. We were informed plans were to be put in place to provide this training to the staff team.

During our observations we were not assured people were receiving person centred care to support their individual needs. We observed during the day and during meal times there were not always enough staff to support people with their individual needs. This included providing people with 1:1 support with their meal and when people were observed to become upset or need reassurance. We observed one person who was knocking the table with their hand and elbow whilst waiting for their lunch and another person who we observed for over 30 minutes wait for a member of staff to support them with their lunch. However, the member of staff who was allocated to support them that day was out with another person in the community. We also observed another person who was showing signs of distress for some time not being provided with support until we raised this directly with a staff member.

Care plans were detailed and contained hospital passports. These gave staff important information about how to support people with their mobility, personal care, dietary and medical needs. People had personal evacuation plans in place. These confirmed what support the person required, along with any equipment they would need assistance within the event of an emergency. Improvements were needed to ensure risk assessments were in place for supporting people with equipment such as bed and floor sensors, to manage risks when showering, and where people’s skin integrity could be compromised. Improvements were also needed to the storage of equipment throughout the service as this was stored within bathrooms and communal areas. Incidents and accidents were not always being logged and records were not always in place where people had communicated their anxieties and needs through their behaviours. People were not always being supported with referrals to external health professionals when required. Where referrals had been made they had not always been accepted, and we found more information was available that could have been provided to support the referral such as from people’s daily notes, incident and accidents and behaviour charts. We informed the interim manager of our findings. By keeping a record of all incidents and accidents and any other information means any trends and themes can be monitored along with providing more detail when referrals are made. Improvements were needed to ensure staff had received training in how to support people with positive behaviour support and how incidents and accidents are recorded. For example, if an incident had not been observed staff were only completing a body map. The risks to people’s care and treatment had not always been assessed, not all incidents and changes to people’s behaviour were being recorded and referrals for external support had not always been made when required.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives said there was a high turnover of staff within the home. We heard “There’s always a lot of new faces, there’s a high turnover of staff, that’s for sure” and the home was “Short staffed but now there are new staff”. We heard how staff shortages had affected people. One person told us they did not get to do all the things they wanted to do, as going out was sometimes dependent on staff being available. One relative told us [person] used to “go out quite often” but “doesn’t go so much now”. We also heard of the positive impact a staff member had on a resident and were told they had been doing things they had “never done before”. When asked if staff had the training and skills to support people safely relatives told us “I think they’re well trained, the new ones are…well I think they are” and another said, “They’re trained yes, but not sure about mental health [(training])”. During our site visit we found people were not always being given their medicines in the correct way in line with their SALT guidance which could put people at an increased risk of choking.

Staff told us they completed an induction when they started working at the service, which included shadow shifts and training. The training was relevant to their roles and responsibilities such as moving and handling, this was a mix of online and face to face training. Staff new to care had also completed the care certificate. Staff spoke positively about how they support people. For example, they told us they support people to choose what they would like to wear and what breakfast and meal choices they would like. One member of staff told us how they support someone who needs additional assistance and reassurance with their care as they had sensory impairments. They explained how they provide a relaxed and supportive approach to them reassuring and guiding them through the support and care they needed. Staff we spoke to said there were enough staff to provide good and safe care to people, this included during the night and at weekends. Extra staff to support people who had appointments was planned for within the staffing rotas. Staff sickness did have an impact, although the management team did what they could to try and cover the shifts. However we were not assured during our site visits there were enough staff to provide people with effective care. Not all staff had received the medicines training they required in areas such as epilepsy rescue medication and controlled drugs, which could put people at significant risk of harm.

Some people were not being provided with care that assured us that staff understood people's needs and were following care plans. We observed some people, whose care plan states they do not communicate verbally and may injure themselves, were left on their own for long periods of time without interaction from staff apart from at meal times. We observed people within the home spend time in the communal areas. They spent time sitting on couches with the television on. However, we observed very little interaction from staff to support people with any activities or conversations about how the person might like to be supported or what they would like to do that day. We observed people were not always supported by staff and staff were not always available to provide reassurance and positive interactions with people when they became upset or needed assistance. For example, we observed one person who was left most of the day in a top that was wet from saliva.

Recruitment checks were being completed however we identified some gaps in people’s employment history and some queries around information on peoples CV and references. The provider had acted prior to our assessment to request additional information. The provider was not always facilitating training to support people's identified care needs. We found one staff member had not received training in medicine management, epilepsy, or epilepsy rescue medicine. Not all night staff who administer medicines including controlled drugs, had undergone specific medicines training including training for administering controlled drugs. The service was not providing learning disabilities training for staff that was specific for their role despite this being a requirement in the Health and Care Act 2022. Providers must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role. Training records we viewed did not demonstrate people had been adequately trained to support people with learning disabilities and autism. The provider had identified this and we saw they had an action on their service improvement plan for the required training to be provided for staff. It was unclear from the information we reviewed the levels of support that people needed or were being provided. We were not assured there were always enough staff to meet people’s needs. Staff were not always trained and skilled to meet the needs of the people living at the service. Audits we reviewed had not always identified these shortfalls.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us that medicines prescribed for specific conditions such as epilepsy was effective and their loved one’s epilepsy was “well controlled”. We also heard how a medicines review had led to a reduction in prescribed medication and the person was “now 100% better than where (person) was”. One relative told us they were not aware of medicines reviews. Another relative said an epilepsy nurse “goes in to see [person] every couple of weeks”. We were not assured all staff were trained and skilled to provide safe medicines care to people. We observed 2 people being given medicines in a different way than was recorded in their care plan. Both people were at risk of choking and had a speech and language therapist (SALT) plan in place. Giving medication in an alternative way than advised could put them at increased risk of choking.

Staff we spoke to, who were trained to administer medications told us their competency in the administration process was also checked. They told us they were confident in the process to follow when a medication error occurred, or if a controlled drug was required to be administered. However not all staff we observed administering medication were able to tell us why medication was prescribed for the person or the way the medication should be given in line with the information in the person’s medicines record.

The service was carrying out regular audits on medicines, whilst these showed where medicine errors had occurred the audits completed did not identify where people had missed doses of their medicines. We did not see in the medication audits or records what action should be taken if a person regularly missed medication. We saw medication records that showed a person had missed 6 doses of medication in a month but did not see evidence that any medical advice had been sought because of this. This is important because some people need to take their medication regularly for it to be effective, such as when managing conditions such as epilepsy. Medicine competency checks had been completed recently for most staff, however most staff had not undertaken thickening fluids training. This is important because there are people at the service who are on a SALT plan and have their fluid thickened. People were at risk of harm because staff did not know or were not following specific medicines guidance in place for people. Medicines audits completed by the service had not identified these concerns.