Birch Tree Manor

Updated 15 December 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. 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 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 one 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 Tree Manor is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with CQC. This means that they and the provider are 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

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and local Healthwatch. 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.

During the inspection

We spoke with two people who lived in the home about their experience of the care provided. We spoke with seven members of staff employed including the registered manager, one nurse and five care staff. We also spoke with twelve people’s relatives.

We completed checks of the premises and observed how staff cared for and supported people in communal areas. We reviewed a range of records that included four people's care and medication records. We looked at five staff files in relation to recruitment and staff supervision. We also looked at a variety of records relating to the management of the service, including audits, policies and procedures, and accidents records.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at audit and governance data, as well as infection prevention and control policies and procedures.

Updated 15 December 2021

About the service

Birch Tree Manor is a 'care home' providing accommodation, nursing and personal care for up to 62 older people; some of whom lived with dementia. At the time of the inspection 57 people were living at the home.

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

People were not fully protected from the spread of infection. COVID 19 weekly testing regimes were not always carried out in line with government guidance. Parts of the environment were not kept clean and hygienic and staff did not always wear the correct level of PPE. These matters were addressed at the inspection.

People told us they were happy with the care they received and said they felt safe living at the home. One person said, " Everyone is really nice." People living at the home were comfortable with staff. Staff spent time chatting with people and supporting them when they became distressed.

People were protected from abuse because staff understood what was meant by abuse and the correct procedures to follow if they had any concerns about people’s safety. People received their medicines as prescribed and staff had clear information about how people liked to be supported with their medicines. Staff were knowledgeable about people's health needs and the provider had sought support from other health professionals as appropriate to support people's needs.

Risks were not always fully assessed, monitored and reviewed. Risks such as choking, and weight monitoring was not always monitored appropriately. Some key information in people’s care records about the management of risk was not accurate.

Staffing levels were appropriate and matched the dependency tool being used to match the needs of people at the home. The home used a moderate volume of agency staff. The provider assured us that they were continuously working to recruit more permanent staff. Staff received training and support to enable them to effectively meet the needs of the people they supported.

Rating at last inspection

The last rating for this service was requires Improvement (published 23 December 2020).

Why we inspected

We carried out an unannounced focused inspection of this service on 1 November 2021 following a number of concerns relating to COVID-19 testing and intelligence gathered through various sources and our system. This report only covers our findings in relation to the Key Questions of Safe and Well-led.

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.

Our report is only based on the findings in those areas at this inspection. The ratings from the previous comprehensive inspection for the caring, effective and responsive key questions were not looked at during this visit. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used to calculate the overall rating at this inspection.

The overall rating for the service has remained 'requires improvement'. This is based on the findings at this inspection. We found evidence that the provider still needs to make improvements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Birch Tree Manor on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

At this inspection we have identified breaches in relation to safe care. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.