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Birchwood Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 26 June 2019

About the service:

Birchwood is a care home which accommodates up to 15 people with physical disabilities and sensory impairment. At the time of our inspection 14 people used the service.

People’s experience of using this service:

We found breaches of regulations 12, 13 and 19 of the Health and Social Care Act (Regulated Activities) Regulations 2014. We have made recommendations about risk assessments, safeguarding training, infection control. People were not always protected from the risk of potential harm. Actions taken by the provider in response to allegations of abuse were not always robust, timely or effective to protect people from reoccurrences of these incidents. The service’s management of environmental, equipment-related risks and safety checks were inconsistent and did not comply with health and safety requirements. People did not always receive their medicines as prescribed. Medicines were not always stored safely and records were not in line with national guidance. Staff recruitment checks regarding gaps in employment history and disclosure and barring service (DBS) were not always followed-up and risk assessed in accordance with the provider’s policy and procedure. People’s risk assessments met their individual needs.

We found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. The service did not always report notifiable events to Care Quality Commission (CQC) in line with requirements. We found the service had not notified us of nine medicines administration errors which were reported to the local authority safeguarding team. We have made a recommendation about quality assurance and audit processes. Quality monitoring checks did not always effectively identify or address areas requiring improvement. Staff were committed to people using the service and said they felt supported by the current registered manager and team leaders. The service engaged with people to gain their feedback and worked effectively in partnership with volunteers and health and social care professionals to meet people’s needs.

We have made recommendations about the environment and facilities of the service to meet people’s needs and about equality monitoring for staff. Some equipment was faulty and some people’s furniture was in disrepair. The provider had implemented technology to support people’s independence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People received support from staff who received ongoing training, supervision and support.

Staff treated people with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Relatives, relevant professionals and advocates were involved in people’s care and treatment.

Care planning documentation was up-to-date and met people’s needs. The registered manager and staff demonstrated detailed knowledge of people’s needs and preferences. The service accommodated people’s interests and facilitated a range of activities. Complaints were logged and investigated.

Rating at last inspection: The service was registered by CQC with a new provider on 30 April 2018. This was the first inspection visit to the service under the new provider.

Rating at last inspection:

The last rating for this service was requires improvement (published 16 September 2017). Since this rating was awarded the registered provider of the service has changed. We have used the previous rating to inform our planning and decisions about the rating at this inspection.

Why we inspected:

This inspection was part of our scheduled plan of visiting services to check the safety and quality of care.


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 and intelligence we receive about

Inspection areas


Requires improvement

Updated 26 June 2019

The service was not always safe.

Details are in our Safe findings below.



Updated 26 June 2019

The service was effective.

Details are in our Effective findings below.



Updated 26 June 2019

The service was caring.

Details are in our Caring findings below.



Updated 26 June 2019

The service was responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 26 June 2019

The service was not always well-led.

Details are in our Well-Led findings below.