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.