Birkinshaw Manor

Updated 17 February 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of one inspector.

Service and service type

Birkinshaw Manor is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Birkinshaw Manor is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with three people who used the service and three relatives of people living at the home. We spoke with the registered manager, two senior care workers, a care worker, a member of the domestic staff and an activities co-ordinator. We also spoke with the provider’s management associate. We looked at four care plans and a range of other clinical and management documents including medicine records and audit documentation.

Following the inspection, we received email testimony from three staff members, two relatives and a health professional. We also spoke with a relative on the telephone.

Updated 17 February 2023

About the service

Birkinshaw Manor is a residential care home providing the regulated activity Accommodation for persons who require nursing or personal care for to up to 54 people. The service provides support to older people, including those living with dementia, people with a physical disability and younger adults. At the time of our inspection there were 40 people using the service.

Birkinshaw manor is a purpose-built care home offering care and accommodation for up to 54 people. The home consists of purpose-built accommodation with rooms spread over 3 floors. All rooms have en suite facilities and there are a range of communal facilities such as lounge areas, dining room, a cinema room, library and other amenities.

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

People were cared for effectively and safely. Some risk assessments needed more detail. Any safeguarding concerns were reported and investigated. There were sufficient numbers of staff to support people with their care needs, although some people commented on the high use of agency staff. The services tried to use regular agency staff members, so they were familiar with people's needs. Medicines were managed safely, and medicine records were up to date. The home was clean and tidy and appropriate infection control procedures were followed. Accidents and incidents were recorded and monitored. The provider had acted on previous recommendations regarding mealtimes and activities at the home.

People, relatives and staff told us management of the home had improved significantly. Staff told us morale had improved and there was a good working team at the home. Relatives told us they had witnessed significant improvements in care and the overall running of the home. A range of checks and audits were undertaken. Some records were not always up to date or well-maintained. We have made a recommendation about this. The service looked to involve staff and people in care decisions and worked closely with outside professionals.

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 and update

The last rating for this service was requires improvement (published 10 August 2022)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider review activities at the home and ensure that people’s mealtimes were a positive experience. At this inspection we found provider had acted on these recommendations. Activities had improved and were praised by people, relatives and staff. Meals times were appropriate to people’s needs.

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 carried out an unannounced comprehensive inspection of this service on 29 and 30 March 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance and compliance with the duty of candour regulations.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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

Recommendations

We have recommended the provider review and improve the keeping and storage of daily records and some audit records.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.