Archived: Birchley Hall

Updated 30 March 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 was planned to check whether the registered 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 was unannounced and took place over one day. Two adult social care inspectors carried out the inspection.

We observed the interaction between people who used the service and staff and we spoke with eight people and five family members. We spoke with the registered manager, and staff who held various roles including, care staff, kitchen staff and domestic staff. We also spoke with a visiting healthcare professional.

We looked at areas of the service including the main communal lounge, dining room, bathrooms, bedrooms, the kitchen and the laundry.

We reviewed a number of records, including care records for four people who used the service and three staff files. Other records we looked at which related to the management of the service included quality monitoring audits and safety certificates for equipment and systems in use at the service.

Before our inspection we reviewed the information we held about the service including notifications that the registered provider had sent us. Other information we looked at included information we received from the local authority and members of the public and the Provider Information Return (PIR). The PIR is a form that asks the provider to give some key information about the service, including what the service does well and any improvements they plan to make.

Updated 30 March 2017

This inspection was carried out on 15 February 2017 and was unannounced.

Birchley Hall is a care home providing accommodation for up to 28 people. Accommodation is provided over two floors. Bedrooms located on the first floor can be accessed via a stair case or passenger lift. There were 25 people using the service at the time of our inspection.

The service has a registered manager who was registered with the Care Quality Commission in June 2016. A registered manager is a person who has registered with the Care Quality Commission to manage 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.

This was the first inspection of the service since it was taken over by the current registered provider.

We found during this inspection that the registered provider was not meeting the requirements of the Health and Social Care Act 2008 and associated Regulations in relation to good governance.

You can see what action we told the provider to take at the back of the full version of the report.

There were systems in place to check on the quality of the service and to make improvements. Checks were carried out at various intervals on things such as people’s care records, infection control, medication and the environment. However checks on care records did not always identify a lack of reviews and a lack of information regarding people's care. Action plans were put in place to address any improvements identified; however they lacked detail about who was responsible for following up on the action and the timescales for completion.

We have made a recommendation about the environment. Improvements were required to the décor of the environment and to make it more dementia friendly. The décor in parts showed signs of wear and tear and there was a lack of environmental stimulation and signage to support orientation of the building for people living with dementia.

The overall management of medication and associated records was safe. People received their medication on time by staff who had received the appropriate training and competency checks. However protocols for PRN medication, medicines to be taken ‘when required’, were not in place. Although staff followed instructions given by GPs for the use of PRN medication the instructions did not specify the signs and symptoms exhibited by people which indicate when they require the medication. This was actioned immediately.

People were protected from avoidable harm and potential abuse. Clear procedures for preventing abuse and for responding to an allegation of abuse were in place. Staff had undertaken safeguarding training and they were confident about recognising and reporting suspected abuse. The registered manager and other senior staff were aware of their responsibilities to report abuse to relevant agencies.

There were sufficient numbers of suitably skilled and qualified staff to keep people safe. Staff from all departments had completed training in emergency procedures and they were aware of their responsibilities for ensuring people’s safety.

Safe and fair recruitment procedures were followed and staff received an appropriate level of support for their roles. Applicant’s suitability was assessed before they started work at the service. They were required to provide information about their previous employment history, skills and experience and they underwent a series of checks including a check with the Disclosure and Barring service (DBS).

The registered manager and staff had good knowledge and understanding of the Mental Capacity Act (2005) and their roles and responsibilities linked to this. The registered manager worked alongside family members and relevant health and social care professionals to ensure decisions were made in people’s best interests when this was required.

People liked the food and they had access to regular meals, drinks and snacks. People’s nutritional and hydration needs were assessed and planned for and staff had a good understanding of them. People received the support and assistance they needed to eat and drink, including input from dieticians and speech and language therapists.

Care plans contained good descriptions about people’s needs and how they were to be met. Risks to people’s safety and welfare and how to manage them were incorporated into care plans. However some care plans had not been reviewed at the required intervals to make sure they were relevant and up to date. Communication amongst the staff helped to ensure that people received consistent care and support.

Staff were well supported in their roles and responsibilities and provided with relevant training. They were inducted into their roles and underwent annual refresher training in a range of topics. One to one supervisions and group meetings which took place provided staff with an opportunity to discuss matters relating to their work and any training and development needs.

People who used the service, family members and staff said they thought the service was well managed. The registered manager was described as being approachable and supportive. There was an open door policy operated at the service which enabled people to speak openly and in confidence with the registered manager. People were provided with information about how to complain and they said they were confident about complaining should they need to.