Birkdale Village Care Home

Updated 11 February 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 3 February 2022 and was announced. We gave the service one hours’ notice of the inspection.

Updated 11 February 2022

About the service

Birkdale Village Care Home is a residential home providing personal care for people aged 60 and over. There are 19 rooms available with 16 residents living there currently. Birkdale Village is one building, across three floors. All floors are accessible via a lift.

People’s experience of using this service and what we found

People appeared well cared for and looked after. There was a caring and positive culture amongst staff at the service. However, the systems and processes underpinning people’s care were not always safe and robust.

Although we found no evidence that people had been harmed as a result, we identified several areas that put people’s health and safety at potential risk.

The provider did not have an effective system in place to safely manage the administration of people’s medicines. The provider did not have an adequate system in place to learn lessons if mistakes were made. We have made a recommendation about updating some risk assessments, as well as incident recording and audits.

There was a ‘family’ type feel and many of the staff had worked at the service for several years, meaning they knew the people that lived there well. However, although we found no evidence of safeguarding concerns during our inspection, there was a lack of formal systems and processes in place to protect people from the risk of abuse. We have made a recommendation regarding safeguarding processes.

Governance systems were not always effective and needed to be updated, to ensure opportunities were not missed to improve the service. However, the provider did respond positively and effectively to feedback from other professionals, to make improvements to people’s care.

People were protected from the risk of spread of infection especially around COVID-19. At the time of inspection there had been no recorded cases in the service throughout the pandemic. People and relatives said they felt safe and there were enough staff to safely meet their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: The last rating for this service was good (July 2019).

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We received concerns in relation to infection and prevention control, and the governance of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider has taken some actions to mitigate the risks.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Birkdale Village Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to the management of medicines, staff recruitment and monitoring the quality and safety of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.