Archived: Birch Abbey

Updated 5 February 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Birch Abbey is a 'care service'. People in care services 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.

The service did not have a manager registered with the Care Quality Commission. The previous manager had recently left, and the provider was in the process of recruiting to their post. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

Before the inspection we checked the information that we held about the service. This included statutory notifications sent to us by the provider about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send us by law.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

We also obtained feedback from the local authority and the local Healthwatch team. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

During the inspection

We looked around the premises and assessed infection prevention and control practice. We also observed the interactions between people living at the service, care delivery and activities provided at 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.

We spoke with two people living at the service, ten relatives and ten staff who held various roles at the service, including the quality improvement lead, regional manager, deputy manager, nurses and carers. We looked at a range of documentation including five people's care records, medication records, four staff files, accident and incident records, safeguarding records and safety and quality audits.

After the inspection

We continued to seek clarification from the provider to validate evidence. We looked at a range of information relating to safety and quality assurance.

Updated 5 February 2021

About the service

Birch Abbey is a residential home providing personal and nursing care to up to 60 people with a variety of health needs. At the time of our inspection 50 people were living at the service.

Medicines were managed safely in accordance with the relevant guidance for care homes. Following our last inspection, systems to monitor the safety of medicines’ administration had been improved. The building and essential equipment were well-maintained, clean and free from odours. Relatives told us they sometimes had difficulty contacting staff at Birch Abbey. The provider had made recent improvements to the telephone system and building access in response to concerns. Prior to the inspection, we received information of concern regarding staffing levels and the use of agency staff. Safe recruitment procedures were followed, and staff were deployed in sufficient numbers to meet people’s care needs. The home deployed effective measures to manage the risk of infections, including COVID-19. Accident and incident policies and procedures were in place and there was a system to record and report them. There was a recent, noticeable reduction in the number of falls and medicines’ errors following analysis and corrective action. Systems were in place to safeguard people from the risk of abuse.

At the time of the inspection the home did not have a registered manager. However, interim arrangements for the management of the home were robust and effective. Staff understood their roles and responsibilities in relation to safety, quality and compliance with regulations. The home had systems in place to monitor, assess and improve the safety and quality of service being provided. Staff demonstrated kindness and respect in their interactions with people. It was clear they provided care in an individualised manner. The service had improved since our last inspection. Staff and managers demonstrated a commitment to improve further. People living at the service and staff were positive about the current management of the service and the level of communication. Staff engaged well with other health and social care professionals to ensure people’s health and wellbeing was maintained.

Rating at last inspection and update

The last rating for this service was Good (published 12 September 2019). The service remains Good.

Why we inspected

We received concerns in relation to the conduct of staff. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Birch Abbey on our website at www.cqc.org.uk.

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.