Birch Avenue

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Incidents were appropriately reported and internal investigations carried out. However, further improvements were needed to ensure the management team consistently identified and embedded lessons learnt from incidents at service level. There was limited evidence of a learning culture within the service and staff were not always able to learn from incidents or concerns because the management team did not have clear practices and processes in place to support reflection, improvement and accountability. The manager acknowledged our feedback and discussed future implementation of ‘lessons learned’ within staff meetings.

The provider did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Records were not always up to date, and important information was not consistently in people’s care records. This included occasions when people moved into the service. For example, 1 person did not have pre-assessment information in place, despite moving into the home the previous week. This meant staff did not always have accurate and current guidance they needed to support people safely, and this did not promote well informed care planning or safe transitions. However, the manager and senior staff had begun to take steps to improve oversight, including implementing a new reviewing and auditing process. These actions were at an early stage and required embedding into practice.

The provider shared concerns quickly and appropriately and all staff had received appropriate safeguarding training. However, effective safeguarding systems were not fully in place at service level. The local authority told us there were on-going improvements required around safeguarding and the analysis of themes, learning and improvements. We found the safeguarding log had not been fully completed to document outcomes and lessons learned. Therefore, we could not be assured there was effective oversight or auditing taking place within the service. The safeguarding records were amended by leaders following our feedback to include regular audits, outcomes and lessons learned. However, further manager oversight was required to ensure legible and consistent recordings of safeguarding incidents was taking place within the service.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff understood their responsibilities and the key principles of the MCA and DoLS, and we saw any conditions for people were being met. DoLS were being applied for appropriately and the manager tracked the progress of these. Documentation of people’s mental capacity and ability to make specific decisions was recorded appropriately.

The provider did not always work well with people to understand and manage risks. Whilst we found no harm to people, some care records had limited detailed risk assessments in place and for those that existed, we could not be assured they had been reviewed on a regular basis. This reduced staff’s ability to clearly understand people’s needs and deliver care in a safe and consistent manner. For example, 1 person’s care records lacked detail about their specific dietary requirements and how staff safely managed this. However, staff knew people well and information about people’s modified diets was documented in people’s daily notes and the kitchenette’s where food was served, which helped mitigate the risk of harm. We also found a lack of timed observations for some people around welfare and continence checks; these were not always happening on time. This was fed-back to leaders at the time of our assessment, and they commenced implementing more robust systems. However, this required embedding into the culture and practices across the service.

The provider did not always detect and control potential risks in the care environment. Whilst we found no harm to people, environmental risks were not always recognised, mitigated or addressed promptly, which placed people on occasion, at avoidable risk. The service failed to recognise or carry out fire safety measure works which had been identified through an external fire risk assessment. However, the provider promptly addressed the fire risks following our feedback. We also found fire door visual checks, which had been noted as faulty on multiple occasions but had not been rectified in a timely manner. The service could not evidence fire safety evacuations had been completed, and staff told us they had not undertaken routine evacuation exercises. We could not be assured communication within the service was effective around addressing and rectifying environmental risks in a timely manner. Following our assessment, we referred our concerns to the fire service.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff were recruited safely, and appropriate pre-employment processes were in place. We observed people being supported by enough staff to meet their needs. Staff told us they recently struggled with staffing levels. However, under new leadership and rota systems, this had improved. Staff also commented there was more of a focus on supervisions, appraisals and training which had improved staff competency and morale. We received mixed feedback from people and relatives regarding staffing. A family member told us,“I don’t think there is enough staff. My biggest worry is if there wasn’t a member of staff here that knows [relative] well, they wouldn’t understand what [relative] needs. There are never the same staff here.” Another relative told us, “I think they struggle for staff. I think they have fifty/fifty bank and permanent staff. I know the permanent staff, but I don’t really know the bank staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People and relatives praised the domestic staff for maintaining good standards of cleanliness, they told us, “It’s very clean, they clean consistently.” The environment was well maintained, and free from odours. Staff had completed training in infection, prevention and control. We observed staff using personal protective equipment (PPE) appropriately and practising good hand hygiene. We found some equipment, such as washing machines to be out of use for a prolonged period of time, the provider told us they planned to replace these.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. More detailed and regular audits at service level were required to enable staff to identify risks and monitor overall practice. The service commissioned a pharmacy to carry out quarterly audits of medicines at the service. However, we found these audits had not taken place for a significant amount of time. Without structured, regular audits to monitor practice, identify risks, and evidence continuous improvement, the service was unable to demonstrate that people were consistently receiving their medicines as intended, or that emerging issues would be identified and addressed promptly. However, medicines were stored and maintained in line with best practice guidance, and we found people received their medicines safely and as prescribed. Staff had received medicines training and competency checks to ensure they were up to date with required knowledge and skills.