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Birch Heath Lodge Requires improvement

The provider of this service changed - see old profile

We have removed an inspection report for Birch Heath Lodge from 18 September 2019. The removal of the report is not related to the provider or the quality of this service. We found an issue with some of the information gathered by an individual who supported our inspection. We will reinspect this service as soon as possible and publish a new inspection report.
We are carrying out a review of quality at Birch Heath Lodge. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 14 February 2020

About the service

Birch Heath Lodge is a care home providing personal and nursing care to up to 38 people residing in two separate buildings. At the time of the inspection, there were 26 people living in the home, some of whom were living with dementia.

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

The systems in place to monitor the quality and safety of the service were not always effective in identifying areas of the service that required improvement, or the areas of concern we highlighted during the inspection. This is a breach of regulation. The manager took responsive actions to address issues we raised during the inspection. Feedback regarding the service was positive and staff told us they enjoyed their jobs.

Not all care plans contained sufficient, person centred detail and some contained inconsistencies and this was a breach in regulation. Many of these were reviewed and updated by the end of the inspection. It was clear that people or their relatives had been involved in the development of care plans.

Although systems were in place, people’s consent was not always sought and recorded in line with the principles of the Mental Capacity Act and this is a breach of regulation. We found however, that 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.

The environment would benefit from being adapted to help ensure the needs of people living with dementia could be met. Staff were supported in their roles through induction, training and regular supervisions. There was a choice of meal available each day, as well as regular drinks and snacks.

There was a range of activities available to people, both within the home and in the local community. Friends and relatives were able to visit the home at any time and were always made welcome. There was a complaints policy available and people knew how to make a complaint if they needed to.

Staff knew the people they supported well, including their preferences regarding care and people told us staff treated them well. They spoke about people with warmth and compassion. People told us staff provided support in ways that protected their dignity and encouraged their independence. Confidential records regarding people’s care were stored securely to protect people’s privacy.

Staff had been recruited safely and were knowledgeable about safeguarding procedures. Risk to people had been assessed and measures were in place to reduce identified risks. Accidents were reviewed to help prevent recurrence and medicines were managed safely. Staff were aware of emergency procedures, including evacuation of the building.

Rating at last inspection

The last rating for this service was good (published 15 February 2017). There was also an inspection on 12 and 13 August 2019 however, the report following that inspection was withdrawn as there was an issue with some of the information that we gathered.

Why we inspected

This is a planned re-inspection because of the issue highlighted above.


We have identified breaches in relation to gaining people’s consent and the governance of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas



Updated 14 February 2020

The service was safe.

Details are in our safe findings below.


Requires improvement

Updated 14 February 2020

The service was not always effective.

Details are in our effective findings below.



Updated 14 February 2020

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 14 February 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 14 February 2020

The service was not always well-led.

Details are in our well-led findings below.