7 February 2023
During an inspection looking at part of 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.