Updated 5 August 2022
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. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
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 one 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 home’ with nursing care. People in care homes receive accommodation, and/or nursing and personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was a registered manager in post, who was also the provider’s regional manager. However, a new manager had recently started with the intention of becoming the sole registered manager for the service.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with three people who used the service and four relatives who shared their views of the service. We spoke with twelve members of staff, including the registered manager, the manager, deputy manager, a nurse, two senior carers, four carers, the maintenance person and a housekeeping member of staff.
We had a walk around the service to make sure it was suitable and safe. We observed the care and support people received during different times throughout the day, to help us understand the experience of people who could not talk with us.
We reviewed multiple medicine administration records, medicines stocks and storage. We looked at records relating to environmental checks. We reviewed four staff files in relation to recruitment.
After the inspection
After the inspection we continued to seek clarification from the provider to validate evidence found. We looked at a variety of records relating to the management of the service, including policies and procedures. We reviewed four care plans and looked at quality assurance documents.