Birch Avenue

Updated 19 January 2026

Date of assessment: 02 to 16 of February 2026.

Birch Avenue is a one-storey purpose-built home and provides nursing care for up to 40 older people, all of whom were living with dementia. The home has 4, 10 bedded 'bungalows' with an interlinking corridor surrounding a large garden and patio area. Each unit has a communal lounge and dining room. All 40 bedrooms are single and have en-suite facilities. There is also a central kitchen and laundry. At the time of our assessment, 30 people were living at the service. We carried out a comprehensive assessment of the service covering all quality statements, in all key questions. This assessment was carried out due to an increase in risk being highlighted to us from professionals, and public concerns being raised.

We found 2 breaches of regulation relating to safe care and treatment and good governance. The service was previously rated good in 2023. The service is now rated requires improvement.

The service were aware of shortfalls in people’s care records and were currently working with the local authority to improve safe care and treatment for people. However, we found the service did not always ensure risks to people were assessed and managed. Care plans lacked guidance in relation to risks associated with people’s diagnosed health conditions. There was a lack of robust assessment of people’s needs. The service did not always provide evidence-based care and treatment for people, such as meaningful activities and did not review clinical monitoring tools in a timely manner.

There was a lack of effective governance, oversight and monitoring of the service and governance processes did not identify the issues we found during this assessment. Quality assurance systems and processes were not effectively implemented to ensure safety and drive improvements. There was a lack of oversight and knowledge from leaders at all levels around roles, responsibilities and accountability to enable good governance.

However, we found staff knew people well, spoke positively about their roles and felt supported by the management team. Our observations of care provided were positive, and people and their relatives told us they were satisfied with the service. The service responded positively to the shortfalls identified. We asked the service for an action plan in response to the concerns found at this assessment.

Updated 19 January 2026

People’s care records were not always person-centred and did not consistently contain details of people’s preferences. However, people and their relatives were involved in decision making and told us they were asked for their input around assessments. Staff sought consent from people, and if they lacked capacity, decisions were made in their best interests.People and their relatives spoke positively about the care and support provided. People told us they felt safe, and trusted staff to treat them well. A relative said, “Absolutely safe, it works for me. I feel the staff have a lot of patience.” And “Yes, I think [relative] is safe, I am quite happy with the care they get.” Some people and relatives commented on staffing levels, telling us, “[Relative] does fall over a lot, about two times a month. I think it may be as there are not enough staff around to watch [relative].” And, “I know the permanent staff, but I don’t really know the bank staff. I think more permanent staff are needed. It’s important that [relative] has people they recognise.” People and relatives knew how to raise any concerns if they needed to and told us staff and management were approachable and responsive. A relative told us, “I can talk to them [managers] if I needed to.”