Birch Heath Lodge

Updated 25 March 2023

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

This inspection was carried out by 2 inspectors.

Service and service type

Birch Heath Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Birch Heath Lodge is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post for 4 months and had submitted an application to register. We are currently assessing this application.

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 8 people who used the service and 5 relatives about their experience of the care provided. We observed interactions between staff and people living at Birch Heath Lodge. We spoke with 8 members of staff in various roles.

We reviewed a range of records. We reviewed 6 people's care records and other records relating to people’s care and support. We looked at 8 staff files in relation to recruitment. A variety of records relating to the management of the service was reviewed, including policies and procedures.

Updated 25 March 2023

About the service

Birch Heath Lodge is a residential care home providing personal and nursing care to 30 people aged 65 and over at the time of the inspection. The service can support up to 38 people. Accommodation is provided across two buildings with shared garden and communal facilities.

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

Processes in place to effectively monitor risk and provide appropriate support were not robust which put people at risk of harm. We discussed our concerns with staff and the manager during the inspection who acted immediately to investigate the concerns raised and reduce the risk.

Systems in place were not always robust to demonstrate that physical health was being monitored by the management team and required support provided to people was taking place. We raised this to the manager who took step to address the concerns raised during the inspection.

We received mix responses from people and relatives regarding staffing levels. The provider was able to demonstrate a dependency tool which assessed the amount of staff needed. During the inspection we saw people having support when they requested it, however people informed us they needed to be patient at times. We discussed this with the manager and have made a recommendation about monitoring how staff are deployed across the service in line with people’s dependency.

Although processes were in place to assess people under the principles of the Mental Capacity Act (MCA) we found that the service was not always working in line with this. We spoke to the manager regarding our concerns and recommended they reviewed information held on people.

People were supported to have 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 were not always followed to supported this practice.

Safe recruitment processes were followed. Staff received on-going training and development to support them in their roles.

Staff spoke positively about the management team and felt supported to develop in their roles .

People who lived in the service overall spoke positively about the staff in the service and the support they received.

The manager was open and proactive during the inspection regarding identified concerns and proactive to address risk.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 27 February 2021) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations. The service remains requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection.

Enforcement and Recommendations and update

At our last inspection we identified a breach of Good governance. At this inspection we found the provider was still in breach of this regulation

We identified a further breach that systems were not robust enough to demonstrate people were supported safely and that risk was managed.

We recommended the provider reviews how staff are deployed in the service in line with people's needs.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.