Birchwood Care Home

Birchwood Care Home is a care home with nursing that provides personal care for up to 60 older people, some of whom may be living with dementia, physical disabilities or sensory impairments. At the time of our inspection there were 39 people living at the service.

There are five separate units within the home, namely Maple, Oak, Pine, Ash and Walnut, set across three floors. Each unit is self-contained with communal and dining rooms. People with more complex nursing needs live on the first floor (Maple and Oak units), whilst people living with dementia are mainly located on the first floor (Pine and Ash units). More independent people live on the ground floor (Walnut unit). People had individual bedrooms with en-suite bathroom facilities. The care home is situated in a residential area. There is a large garden to the rear and side of the building.

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

The provider had not effectively operated assessment and monitoring processes, to ensure that quality and safety were not compromised and risks to people were mitigated, in compliance with regulations. Care plans did not always contain specific risk assessments and management plans to support people who experienced seizures. Medicines were not always managed safely.

People were protected from avoidable harm by staff who had completed safeguarding training and knew how to recognise and report abuse. The manager ensured enough suitable staff were deployed to meet people’s needs safely. Staff completed a robust recruitment process, which explored their conduct in previous care roles, to assure their suitability to support older people. Staff maintained high standards of cleanliness and hygiene in the home, which reduced the risk of infection, in accordance with provider's policies and procedures, and government guidance.

Staff assessed all aspects of people’s physical, emotional and social needs and ensured these were met to achieve good outcomes for them. Managers effectively supported staff to develop and maintain the skills to support people according to their needs. Staff emphasised the importance of eating and drinking well and reflected best practice in how they supported people to maintain a healthy balanced diet. Staff identified when people’s needs changed and quickly sought guidance from health care professionals. This ensured people received the appropriate care to keep them safe and well. The home had been purpose built to accommodate older people and was subject to a rolling programme of assessment and adaptation. This ensured the environment remained dementia friendly.

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.

People experienced caring relationships where staff treated them with kindness and compassion in their day-to-day care. People were supported to be independent and make decisions about their care. People’s choices were supported by staff, who treated people with dignity and respect. Staff knew how to comfort and reassure different people when they were worried or confused.

People experienced person-centred care, which consistently achieved good outcomes and had significantly improved the quality of their lives. People received information in a way they could understand, allowing for any impairment, such as poor eyesight or hearing. People were enabled to live as full a life as possible and were supported to take part in activities, which enriched their lives. People were supported to keep in touch with family and friends, which had a positive impact on their well-being. People and relatives knew how to make complaints and were confident the management team would listen and address their concerns. The service worked closely with health care professionals and provided good end of life care, which respected people’s wishes and ensured they experienced a comfortable, dignified and pain-free death.

The management team led by example and promoted a strong caring, person-centred culture where people and staff felt valued. Staff were passionate about their role and consistently placed people at the heart of the service. The manager understood their responsibilities to inform people when things went wrong and the importance of conducting thorough investigations to identify lessons learnt to prevent further occurrences.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 25 August 2022). The service remains rated requires improvement.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 11 July 2022. Six breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance, safe care and treatment, staffing, fit and proper persons employed, need for consent, dignity and respect.

We undertook this comprehensive follow up inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the Key Questions Safe, Effective, Caring, Responsive and Well-led which contain those requirements.

At our last inspection we recommended people’s views, and those of legally appointed representatives, were sought when planning and reviewing their care and support. At this inspection we found the manager had implemented our recommendations which had led to the required improvements.

Enforcement

We have identified breaches in relation to safe care and treatment, unsafe management of medicines and good governance.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Birchwood Care Home is a residential care home providing personal and nursing care to 43 people aged 65 and over at the time of the inspection. The service can support up to 60 people. Some people at the care home are living with dementia, physical disabilities or sensory impairments.

The care home is located in a residential area. There are five separate units, set across three floors. Each person has their own bedroom and en-suite bathroom facilities. There are communal areas such as lounge rooms and dining rooms. There is a large garden to the rear and side of the building.

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

The provider’s systems and processes for monitoring and improving quality and safety in the service had not been used effectively to fully address the shortfalls in service delivery.

The provider had not effectively assessed, monitored and mitigated the risks relating to the health, safety and welfare of service users or effectively sought and acted on feedback from people using the service to drive improvements.

Risk assessments lacked sufficiently clear guidance to help staff mitigate risks for people. Some staff had either not completed or not renewed their safeguarding training. Although medicines audits had been put in place there were a significant number of medicines errors. Recruitment files did not contain all of the required information.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Assessments of people’s Mental capacity and documents regarding decisions made in people’s best interests had not been updated or reviewed.

People’s dignity was not always upheld. People were not always involved in planning their care and support. People’s needs and wishes for the support they wished to receive at the end of their lives were not always effectively assessed and documented.

There were enough staff to provide safe care. Safeguarding concerns were reported appropriately to the local authority and to CQC. Infection prevention and control practices were in place to protect people from the spread of infection.

People were supported to maintain a healthy dietary intake. Staff worked cooperatively with professionals from health and social care to promote their health and wellbeing.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was rated requires improvement (published 21 April 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We undertook this inspection to follow up on action we told the provider to take at the last inspection. We also looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see all the sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Birchwood Care Home is a residential care home providing personal and nursing care to 49 people aged 65 and over at the time of the inspection. The service can support up to 60 people. Some people at the care home are living with dementia, physical disabilities or sensory impairments.

The care home is located in a residential area. There are five separate units, set across three floors. Each person has their own bedroom and en-suite bathroom facilities. There are communal areas such as lounge rooms and dining rooms. There is a large garden to the rear and side of the building.

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

Leadership, management and governance systems were poor and did not demonstrate the service was well led, people were safe, or their care and support needs were being consistently met. Systems in place to oversee the service and ensure compliance with the fundamental standards were not always effective. They did not enable the manager and provider to identify when their legal responsibilities were not being met. The health, safety and welfare of people using the service were not always managed effectively and required records were not always kept or available. Risks to people were not always regularly reviewed to enable staff to provide safe care.

Medicines were not managed safely. People were placed at risk of harm due to a lack of information for staff about how to manage people's medicines. Audits of people’s medicines were not completed consistently and not used effectively to address errors and omissions. Suitably qualified staff were not always deployed to administer people’s medicines safely. Incidents and accidents were not analysed to prevent recurrences and keep people safe.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was rated good (published 4 June 2021). At this inspection the service deteriorated to requires improvement.

Why we inspected

The inspection was prompted in part due to concerns received about medicines, infection control, and the management of the service. We decided to inspect and examine those risks.

This report only covers our findings in relation to the key questions of Safe and Well-Led. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. We have found evidence that the provider needs to make improvements.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Birchwood Care Home on our website at www.cqc.org.uk.

Enforcement and recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, staffing and good governance. Please see the action we have told the provider to take at the end of this report.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Birchwood Care Home is a residential care home providing personal and nursing care to 49 people aged 65 and over at the time of the inspection. The service can support up to 60 people. There are approximately 90 staff. Some people at the care home are living with dementia, physical disabilities or sensory impairments.

The care home is located in a residential area. The building is modern and purpose-built. There are five separate units, set across three floors. Each person has their own bedroom and ensuite bathroom facilities. There are communal areas such has lounge rooms and dining rooms. There is a large garden to the rear and side of the building.

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

Improvements were made since our last inspection to ensure people received safer care. Risk assessments were improved. There was sufficient staff deployed and personnel file contents were improved. Medicines management was made safer and we noted the improvements made. People were protected from abuse and neglect. Accidents and incidents were logged; the service still needed to demonstrate how they learn and change as a result of reported accidents and incidents. We made a recommendation about recording mechanisms for incidents. People and others were satisfactorily protected from COVID-19 at the time of the inspection.

At this inspection, we have repeated our recommendation about the dining experience for people. The food, drinks and dining experience at the service were being improved through regular meetings with the caterers. Staff were knowledgeable, experienced and skilled. They carefully provided the support people required. There was an appropriate induction, training, supervision and performance appraisal system which enabled staff to progress their careers. Refurbishment of the environment was ongoing; the provider was signposted to resources about the right decoration for people living with dementia.

People and relatives described the service as caring and staff as kind. They provided positive feedback about their interactions with staff. People’s human rights, dignity and privacy were respected. The support people received helped promote and maintain people’s independence.

Improvements were made to people’s care plan documents. This demonstrated planned care was tailored to their individual needs. There was a large variety of social activities, which prevented isolation and promoted people’s emotional health and psychological wellbeing during the pandemic. There was an appropriate complaints system in place. We made a recommendation about storage of complaints documents.

Improvements were made to the governance of the service since our last inspection. However, further action is required to ensure the service is always well-led. The registered manager had not always carried out all steps in the duty of candour process. We made a recommendation about the duty of candour process. Most notifications of specific events had been sent to us. A continuous audit and action plan was in place which clearly demonstrated improvements made by the management team. The service engaged well with people, staff and relatives. The management team were receptive to feedback and implemented suggestions and improvements. There was good collaborative working with healthcare and social care partners.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 20 November 2019) and there were multiple breaches of the regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. We also took enforcement action to impose conditions on the provider’s registration. At this inspection, we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under key question Safe. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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.

Birchwood is a residential care home with nursing. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home provides facilities over three floors. There were five units in the home across these three floors. People had their own bedrooms with en-suite facilities and use of an enclosed private garden. Some of the people supported at the home live with dementia and other health related conditions. The service is registered to provide accommodation with personal and nursing care for up to 60 people. At the time of our inspection the home was supporting 54 people.

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

The service assessed risks to the health and wellbeing of people who use the service and staff. However, care was not always delivered by staff in line with people’s care plans to mitigate these risks. Safe recruitment practices were not always followed to make sure, as far as possible, that people were protected from staff being employed who were not suitable. Staff were not always deployed effectively to meet people’s needs.

Records did always reflect a clear care and treatment plan of people’s individual needs and preferences. We could not be assured appropriate person-centred care and treatment that was responsive to people’s needs. People’s end of life needs wishes, and preferences had not always been explored.

Care records were not always up to date and accurate. Audit and governance systems were not always effective. The registered person failed to notify the Commission of notifiable events.

People’s dining experience was not always person-centred to meet people’s needs. We have made a recommendation that the provider seeks guidance in line with best practice on ensuring people’s dining experience is more person-centred and meets people’s needs

Whilst actions had been taken by the registered provider to make the environment more dementia friendly, further improvement could be made. We have made a recommendation that the provider takes further action in line with best practice to ensure they make environments used by people living with dementia more dementia friendly.

Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately. People and their relatives knew how to complain and knew the process to follow if they had concerns. People, relatives and staff felt they could approach management with any concerns they may have.

People experienced support that was compassionate and caring, from staff they had developed meaningful relationships with and who knew them well.

Staff understood the principles of the Mental Capacity Act and the importance of people making their own decisions. 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.

People had their healthcare needs identified and were able to access healthcare professionals such as their GP, when needed. The service worked well with other health and social care professionals to provide effective care for people.

The service had regular residents and relatives' meetings as well as staff meetings to ensure there was opportunity to feedback about the home and that there would be a consistency in action taken. The staff team had handovers and daily meetings to discuss matters relating to the service and people’s care.

Without exception, relatives and healthcare professionals spoke highly of the registered manager and their commitment to delivering a high quality service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (report published 21 August 2018) and there were breaches in regulation 9 (Person-centred care), regulation 10 (Dignity and respect), regulation 12 (Safe care and treatment), regulation 17 (Good governance) and regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the registered provider was still in breach of regulations 9 (Person-centred care), regulation 12 (Safe care and treatment), regulation 17 (Good governance) and regulation 19 (Fit and proper persons employed). The provider was also in breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and regulation 18 (Notification of other incidents) of the Care Quality Commission (Registration) Regulations 2009.

Why we inspected

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to regulations 9 (Person-centred care), regulation 12 (Safe care and treatment), regulation 17 (Good governance) and regulation 19 (Fit and proper persons employed). The provider was also in breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and regulation 18 (Notification of other incidents) of the Care Quality Commission (Registration) Regulations 2009.

We have imposed a condition on the providers registration which requires them to submit a monthly report to the Care Quality Commission on the actions being taken to ensure improvements are being made to the quality and safety of the service.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This inspection was completed on 31st May and 4th June 2018, and was unannounced on the first day. Birchwood is a 60 bed service that provides facilities over three floors to older adults with varying needs. The ground floor provides a respite service for up to ten people undergoing an assessment period when transitioning from hospital or home and prior to an appropriate care package being sought. The first floor provides residential services to a maximum of 25 people. The second floor provides nursing care to a maximum of 25 people. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. People’s needs varied depending on their diagnosis. We found some people required extensive support whilst others were able to complete some tasks independently.

This inspection was carried out to establish if improvements to meet legal requirements planned by the provider after our October 2017 inspection had been completed. The team inspected the service against all five key areas. This is because the service was not meeting legal requirements and was rated overall as inadequate and placed in special measures. At our last inspection, we found the provider was in breach of nine regulations. Following that inspection, on 22 August 2017, the provider sent an action plan which identified improvements to ensure the service was no longer in breach of the regulations.

At the inspection of October 2017, the provider was rated overall inadequate, with three ratings of inadequate in ‘Safe, ‘Responsive and ‘Well-led. ‘Effective’ and ‘Caring’ were all rated as requiring improvement. At this inspection we found the provider’s had made improvements in all inadequate domains. As a result the overall rating of the service has now been changed to requires improvement. The changes to the key lines of enquiry have meant that additional information is sought in some of the domains.

The service had appointed and registered a new manager in January 2018. However, due to unforeseen circumstances the registered manager had been absent from the service for a period of two months, but had returned to work prior to the inspection. The service was managed by an interim deputy manager, with the additional support of the local authority services manager. However, the management overview remained inconsistent during the period of the registered manager’s absence. 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.

People were not always kept safe. Whilst risk assessments were in place for people, these did not provide information to staff on how to minimise the possibility of a risk. This meant that staff did not always know how to manage a risk should one arise . The provider did not have robust systems in place to ensure sufficient suitably qualified or safe staff were employed to work with people. A criminal records check and photographic identification was missing from staff files and there were gaps in people’s recorded employment history. Of the nine files reviewed all had information missing.

Medicines were not always managed safely, putting people at risk. Covert medicines did not have appropriate directions in place, or evidence of best interest decisions to illustrate how this decision had been reached.

People received care and support from staff who had completed the provider’s identified mandatory training, skills and knowledge to care for them. . The provider had a comprehensive induction process in place that involved both the corporate and location induction.

Staff were appropriately supervised in their role to carry out their duties both safely and effectively. However staff were not always deployed in the most appropriate way to ensure that the experience of people was as they would hope to receive within a timely way.

We were told staff were caring, and ensured people’s dignity was preserved at all times during personal care. However, the language and approach of staff was not always respectful. We found that during mealtimes and when discussing people, the language and approach of staff was not always dignified. During all our observations staff rushed people, offering a task based service, rather than one which was person centred.

The service was not always well-led. Whilst the provider had systems in place to monitor the service, these were not always adequate. The systems in place did not fully maintain an overview of the service. The registered manager was reliant on the provider authorising many of the requirements of the service. The lack of a timely response in responding to many of these requests worked against the service and the registered manager.

We found continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Comprehensive recruitment checks had not been completed to ensure staff were safe to work with people. Care plans although in place, did not contain sufficient information on person centred care. The staff practice further was not always person centred, with language used lacking respect and dignity. Audits although in place, did not fully gather information to ensure the service was delivering care in line with legislation and the fundamental standards. The fundamental standards are regulations 8 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service was taken over by West Berkshire County Council on 1st June 2017, prior to which the care was provided by a corporate service provider. Some of the staff were transferred as part of the acquisition; however senior management within the service was lost.

Birchwood is a 60 bed service that provides facilities over three floors to older adults with varying needs. The ground floor provides a respite service for up to ten people undergoing an assessment period when transitioning from hospital or home and prior to an appropriate care package being sought. The first floor provides residential services to a maximum of 25 people. The second floor provides nursing care to a maximum of 25 people. People’s needs varied depending on their diagnosis. We found some people required extensive support whilst others were able to complete some tasks independently.

A registered manager had been in post since the service was taken over by the local authority. 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.

Notifications had not been made to the CQC for all incidents that were considered safeguarding alerts or reportable as a serious injury. This is a requirement of the registration regulations.

People were not kept safe. Risk assessments and comprehensive documentation was not in place to ensure people were offered responsive safe care and treatment. Care plans contained minimal information, often leaving out crucial information. For example, one care plan did not document how frequently a person required assistance with personal care. This meant they were at risk of their basic needs not being met and increased the potential of the person’s skin being damaged.

Medicines were not managed safely. During a medicine round we observed the medicine trolley was left unlocked and unattended for a brief period of time. A person was witnessed approaching the trolley. MAR charts were completed and errors were noted. However guidelines had not been written for all people who were prescribed medicines to be taken ‘as required’.

Fire safety checks were being completed and recorded. However people were not being kept safe at all times due to a failure in appropriate monitoring and recording of other health and safety checks. Not everyone living or staying at Birchwood had a current personal evacuation plan in place, although staff did have access to one page colour coded list that them who was independent and who needed assistance. Water temperatures checks were not being carried out as required, leading to concerns that staff would be unaware if a thermostatic valve stopped working, putting people at risk of scalding.

Staff did not appropriately record information. Incidents were not reported, and information was not accurately updated in daily records. We noted that one person had sores on both legs, without any dressings. Staff told us that dressings had been removed by the person. No alternative dressing had been applied. Records did not note that the person had sores on legs, what dressing should be applied or how the sores were to be managed.

Staff had not received supervision, or had a team meeting that allowed them to gain an understanding of the provider’s values and vision since taking over.

Neither the provider nor the registered manager had effective systems in place to assess, monitor and improve the quality of the service. There was also no system to assess, monitor and mitigate risks to people using the service, their visitors and staff.

Staff generally were polite and respectful in their approach to people. However much of their role appeared to be task orientated. There were sufficient staff on duty who had received training to support them in their roles. However there were times of the day when staff deployment needed to be considered. The organisation of staff meant that they were not always effective and people’s needs were not being met in a timely way and this, at times, left people unsafe.

During the inspection we identified several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by the CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Services placed in special measures will be inspected again within six months.

• The service will be kept under review and if needed could be escalated to urgent enforcement action