Archived: Birch Abbey

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.

Birch Abbey is a residential care home providing personal and nursing care to 56 people aged 65 and over at the time of the inspection. The service can support up to 60 people living with dementia. The service is divided into four units, each of which has separate adapted facilities.

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

The management of people’s medicines was not consistently safe. During the inspection we noted the registered manager took immediate action to address failings in the administration and recording of people’s medicines and we felt reassured by the action taken.

Improved medicine systems need to be closely monitored and sustained to prevent the risk of avoidable harm for people whom rely on staff to administer their medicines. We have made a recommendation about this.

People received person-centred care and support. We observed staff approach people in a kind and respectful way. People were encouraged to maintain their independence and be involved in making decisions about their care.

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.

Staff understood the importance of protecting people from abuse and procedures were in place to alert the Local Authority when a safeguarding incident had occurred.

People’s risk assessments were not routinely updated following an accident or incident. Staff demonstrated good understanding of people’s needs and told us how they had considered ways to reduce the risk of accidents or incidents happening again.

We received mixed feedback from people who visited the service about staffing levels. Some people told us staffing levels were not always sufficient at the weekend. We discussed this with the registered manager who explained about an increase in the use of agency workers due to unplanned staff absences. We were reassured that the registered manager had listened to people’s feedback and was actively working on ways to reduce staff absence and recruitment of permanent workers.

We observed staff respond to people’s non-verbal communications. Staff understood the needs and preferences of people they supported. There was clear understanding throughout the staff team about best ways to support people living with dementia and people were encouraged to maintain their independence.

Staff told us they were supported and had access to a wide range of training courses.

There was an easy read complaints procedure. The registered manager responded to people’s complaints and people told us the registered manager was approachable.

Staff understood their responsibilities in relation to duty of candour and quality assurance systems were in place to identify where improvements were needed.

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

Rating at last inspection

This service was registered with us on 07/07/2018 because the registered provider changed and this is therefore the first inspection.

The last rating for this service was requires improvement (published 23 May 2018). 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 was a planned inspection.

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.