Archived: Birch Holt Retirement Home

Updated 25 May 2017

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 inspected the service on the 27 and 28 March 2017. This was an unannounced inspection. The inspection team consisted of two inspectors. At the time of our inspection the provider had submitted an application to the CQC to alter their registration status from a partnership to a single provider.

We focused on speaking with people who lived in the home, speaking with staff and observing how people were cared for. We looked at care documentation and records which related to the running of the service. We looked at six care plans and four staff files, all staff training records and quality assurance documentation to support our findings. We looked at records that related to how the home was managed. We also ‘pathway tracked’ people living at Birch Holt. This is when we look at care documentation in depth and obtain views on how people found living there. It is an important part of our inspection, as it allowed us to capture information about a sample of people receiving care.

We looked at areas of the home including people’s bedrooms, bathrooms, lounges and dining area. During our inspection we spoke with nine people who live at Birch Holt, two relatives, seven staff, the provider and manager.

Before our inspection we reviewed the information we held about the home. We had not received an action plan from the provider following our previous inspection in October 2016. We did not request a provider information return (PIR) as this inspection was undertaken at short notice. We considered information which had been shared with us by the local authority and members of the public. We spoke with a representative from the Local Authority’s contracts and monitoring team. We reviewed notifications of incidents and safeguarding documentation that the provider had sent us since our last inspection. A notification is information about important events which the provider is required to tell us about by law.

Updated 25 May 2017

This was an unannounced inspection. Birch Holt provides accommodation, care and support for up to 26 people. On the day of our inspection 13 older people were living at the home. The service provided care and support to people living with dementia, risk of falls and long term healthcare needs such as diabetes.

We carried out an unannounced comprehensive inspection at Birch Holt Retirement Home on 10 and 12 October 2016. Breaches of Regulation were found and the service continued to remain in special measures following a previous rating of Inadequate in November 2015. As a result we undertook this inspection on 27 and 28 March 2017 to follow up on whether the required actions had been taken to address the previous breaches identified. We found some improvements however risks still remained.

A manager was in post, however due to ongoing Registration applications neither the provider nor manager was registered with the Care Quality Commission (CQC) and this is currently an unregistered service. The CQC are taking action to address this matter. A registered manager is a person who has registered with the CQC 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 and associated Regulations about how the service is run.

The ratio of care staff to people on each shift had improved since our last inspection. However there were examples of where the poor management of short notice unavailability of staff and their deployment impacted on responsiveness and the smooth running of the service.

The provider had not undertaken all appropriate checks on staff to ensure their suitability for employment.

We saw examples of poor staff practice in regard to infection control whist they undertook routine care tasks around the home.

Risks related to people’s safety had not always been mitigated effectively. For example with regards to specialist care equipment.

The provider had not taken steps to ensure they were fulling their legal responsibilities in regard to the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

The systems the provider used to track staff training requirements had improved however we found examples where some staff had not completed training in a timely manner. Staff supervision and probationary meetings provided limited feedback that was designed to develop staff’s performance and capability.

We found examples within the service where the culture and staff approach did not consistently promote people’s dignity.

The provider had not made adequate provision to ensure people with the highest care support needs had their social needs met.

Although with support from an external consultant the provider’s quality assurance systems had improved these had not been effectively used by senior staff to provide them with clear oversight of the service.

Despite the concerns we identified during our inspection people wanted to communicate with inspectors that they enjoyed living at Birch Holt Retirement Home and had many positive comments about the service provided.

The management of medicines had improved and people were receiving safe and appropriate support with their medicines. Senior staff had worked collaboratively with the pharmacy service the provider used to establish safe effective systems.

People told us staff were kind and we observed positive interactions between people and staff. We observed various meals, people told us they enjoyed the food and looked forward to coming to the dining room to spend time with others.

At the last comprehensive inspection this provider was placed into special measures by CQC. At this inspection there was not enough improvement to take the provider out of special measures. There were a number of breaches of the regulations. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after all legal requirements have been fulfilled.