Background to this inspection
Updated
20 April 2015
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, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
We visited the service on 06 and 12 February 2015. The first day of our first visit was unannounced and the inspection team consisted of two adult social care inspectors.
On the first day of our visit to the service we spoke with seven people who used the service and we looked at four people’s care records. We looked at records relating to three members of staff. We spoke with four family members and six staff and observed how people were cared for. One adult social care inspector returned to the service for a second day and spoke with a further three people and checked records relating to the running of the service.
We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
Before our inspection we reviewed the information we held about the service including the Provider Information Return (PIR). This is a form in which we ask the provider to give some key information about the service, what the service does well and improvements they plan to make. We reviewed notifications of incidents that the provider had sent us since the last inspection. We contacted local commissioners of the service to obtain their views about it.
Updated
20 April 2015
This was an unannounced inspection, carried out on 06 and 12 February 2015.
Birchley Hall provides care and support for up to 30 people. The premises comprises of 24 single and three double bedrooms and a passenger lift to two floors. There is parking available at the front of the building.
At the time of our inspection there were 18 people living at the service.
There has been no registered manager at the service since August 2014. However, the provider had appointed a manager and they have commenced the process to become the registered manager of the service. 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.
The last inspection of Birchley Hall was carried out in September 2014 and we found that the service was not meeting all the regulations that were assessed. During this inspection we found that the required improvements had been made.
People told us they felt safe at the service and that they were treated well. Family members told us that they had no concerns about their relatives safety. Staff knew what was meant by abuse and they had a good understanding of the procedures they needed to follow for reporting any incidents or suspicions of abuse.
Staff had information about people’s individual needs which included people’s wishes about how they wanted their care and support to be provided. Care plans were regularly reviewed and updated with the involvement of the person they were for to ensure they were accurate and up to date.
Recruitment practices were safe and ensured staff were suitable to work with people in a care setting. Staff received the training and support they needed for their roles and people told us the staff were good at their job. There were sufficient numbers of staff to ensure people’s needs were met in a timely way.
Staff worked well with external health and social care professionals to make sure people received all the care and support they needed. People were referred onto to the appropriate service when concerns about their health or wellbeing were noted. Medication was managed safely and people received their medication on time.
The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. Policies and procedures were in place to guide staff in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Decisions made on behalf of people were made in accordance with the law to ensure they were made in people’s best interests.
People had access to all parts of the home which were kept clean, and safe. Good infection control practices were followed to minimise the spread of infection across the service. Staff knew what their responsibilities were in the event of an outbreak of infection. Staff were confident about dealing with emergencies and emergency equipment was in place and easily accessible.
The service was being well managed by a person who people described as approachable and supportive. Systems for identifying improvements to the service were in place and effective.