Archived: Birchwood

Updated 16 September 2017

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

This inspection took place on 1 and 2 August 2017 and was unannounced.

The inspection was carried out by one inspector and an expert by experience. An expert by experience is someone who has personal experience of using or caring for someone who uses a specific type of care service. Their area of experience was learning disabilities.

Prior to the inspection we reviewed the Provider Information Return (PIR). The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed the information we held about the service and notifications we received. A notification is information about important events which the service is required to send us by law.

During the inspection we spoke with three people who used the service, five relatives who were contacted by phone. We also spoke with five members of staff, the registered manager and the team leader. In addition we observed staff supporting people throughout the service and during the lunch time meal. We also inspected a range of records relating to how the service is run. These included four care plans, four staff files, three Medication Administration Records, (MAR) meeting minutes and the services policies and procedures.

Updated 16 September 2017

Birchwood is a care home which accommodates up to 15 people with physical disabilities and sensory impairment. The service has three bungalows over one site.

Birchwood had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manager 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.

The inspection took place over two days and was unannounced. The previous inspection carried out on 21 May 2015 found the service was meeting the requirements of regulations at that time.

We received mainly positive feedback about the service. Comments included, “I feel safe because I know the staff,” and “They (staff) are always in twos.” Relatives told us that there had been issues in the past but it’s alright now.

There were safeguarding procedures and training on abuse to provide staff with skills and knowledge to recognise and respond to safeguarding concerns.

People received their medicine as specified by the GP. The Medication Administration Records (MAR) had been correctly completed. All staff that administers medicines had been trained in the administration of medicines.

We found sufficient staff were available to meet people’s needs. Recruitment procedures were robust to make sure people were supported by staff with the skills required to carry out their role.

Supervisions were not always taking place on a regular basis to ensure staff felt supported. Staff received training in the services mandatory requirements. However, we saw some staff carrying out procedures without evidence of having training in this area.

Care plans had been written to document the needs and preferences of people living at the service. However, these had not always been kept up to date to reflect people’s changing needs. People had a range of activities they could take part in.

Evacuation plans were in place in the event of an emergency. Fire alarms were tested on a weekly basis and fire drills took place at regular intervals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the service had policies and procedures to support this.

Consent was not always sought for people who had bed rails in place for their safety.

We found records had not been maintained to a good standard and were difficult to locate. We requested some records to be sent to us following our inspection. Auditing systems were not robust to identify where the service needed improvements. Notifications were not always submitted when an incident occurred.

The service was not always cleaned to an acceptable standard. Staff were expected to carry out cleaning duties as part of their daily work. We had no documented evidence of cleaning that had taken place the service did not have a cleaning schedule to confirm areas had been cleaned. We saw opened undated food in one of the services fridge.

We have made recommendations in relation to supervisions and premises and equipment.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the report.