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Archived: Birch Abbey Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 23 May 2018

The inspection took place on 10 & 11 April 2018 and was unannounced. The last inspection of the service was 6 & 7 January and 14 April 2016 and the rating for the service following this inspection was Good.

Birch Abbey is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Birch Abbey is a care home providing personal and nursing care. It can accommodate up to 60 older people. At the time of the inspection 58 people were living at the home. The service specialises in caring for people with dementia.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

At this inspection we found a breach of regulation. People’s plan of care lacked information around care and support. This meant there was a risk staff did not have the information they needed to meet people’s care and support needs effectively and in accordance with individual need and preference. Governance arrangements to asses and monitor standards in the care home were not always effective to ensure the service was managed safely. Record management needed to improve as some information was difficult to locate.

The environment was maintained and subject to service contracts and safety checks of obvious hazards. Not all of these were current though the registered manager took immediate action to rectify this.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person's mental capacity was made. Sixteen people were being supported on a Deprivation of Liberty (DoLS) authorisation. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.

Staff understood the concept of safeguarding knew how to report any concerns. Records indicated that safeguarding referrals to the local authority had been made appropriately.

Medicines were administered safely to people. Staff received medicine training and had been deemed competent for their administration.

Risks to people safety and wellbeing were recorded to enable staff to support people safely whilst promoting their independence. Staff recorded actions to maintain people’ safety.

Accidents and incidents were recorded and analysed to look for patterns and trends.

People at the home were supported by the staff and external health and social care professionals to maintain their health and wellbeing.

Staff were deployed in sufficient numbers to keep people safe and meet their needs.

The registered manager obtained required checks before an employee's commencement in post to ensure staff were suitable to work with vulnerable adults.

Staff received training and support to care for people in accordance with their individual needs. This included more specialised training to support people with dementia.

Our observations showed good interaction by the staff with people they supported. Staff were attentive, kind and respectful in their approach.

Staff were aware of their responsibility to treat people equally and respect their diversity and human rights.

Relatives told us the staff respected their family member’s rights to privacy and dignity and staff looked after people well.

Our discussions with staff confirmed they had a good knowledge and understanding of the people they cared for. We saw care being provided in accordance with individual need.

People’s dietary needs were managed with reference to individual preferences and choice. Pictorial menus were available for people to help choose their meal.

A new social activities programme was in place to help people engage with hobbies they enjoyed and to provide some structure and normality for their day.

Staff were positive about the management and leadership of the home. Staff told us they were able to share their views openly.

A complaints’ procedure was in place and relatives we spoke with were aware of how to raise a concern.

Birch Abbey had a clean environment and we observed good adherence to the control of infection.

Relatives and visitors were welcomed at the home and kept up to date about their family member.

There was a system in place to get feedback from people and/or their relatives so that the service could be developed with respect to their needs and wishes. These included meetings and satisfaction surveys.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory notifications. The ratings from the previous inspection were on display in accordance with requirements.

You can see what action we took at the back of this report.

Inspection areas

Safe

Good

Updated 23 May 2018

The service was safe

Staff were checked when they were recruited to ensure they were suitable to work with vulnerable adults.

Risks associated with people's care and environmental hazards were assessed and actions put in place to mitigate risk.

Medicines were managed safely and consistently monitored.

There were enough staff on duty to help ensure people's care needs were met.

Staff understood the concept of abuse and how to report an actual or potential incident.

Effective

Good

Updated 23 May 2018

The service was effective

People were supported by staff and external professionals to keep them in good health.

Staff were supported through induction, supervision, appraisal and a comprehensive training programme.

When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person's mental capacity was made.

Caring

Good

Updated 23 May 2018

The service was caring

People and their relatives told us the staff were kind, respectful and displayed good communication with them and their family member.

People and their relatives were listened to and felt involved in making decisions about their care.

Staff knew how people liked to be cared for and supported.

Responsive

Requires improvement

Updated 23 May 2018

The service was not always responsive

People’s plan of care lacked information around care and support. This meant there was a risk staff did not have the information they needed to meet people’s care and support needs effectively and in accordance with individual need and preference.

A new activities programme had been introduced which was meaningful and provided good engagement for people.

A process for managing complaints was in place and relatives knew how to complain. Complaints received had been responded to.

Staff had a good understanding of how to provide compassionate end of life care.

Well-led

Requires improvement

Updated 23 May 2018

The service was not always well led

The service's governance arrangements to asses and monitor standards were not always effective to ensure a safe well managed service. Record management was found to be disorganised and a number of records difficult to locate.

The service was led by a management team who were approachable and respected by people, relatives and staff. Staff told us the culture of the service was open and transparent.

There was a system in place to get feedback from people and/or their relatives so that the service could be developed with respect to their needs and wishes. These included meetings and satisfaction surveys.

The Care Quality Commission (CQC) had been notified of reportable incidents in the home.