Birch Hall Care Centre

We have found 4 breaches of regulation at this service in relation to management of medicines, infection prevention and control and the management of risks. As well as person centred care, safe environment and good governance. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and or appeals have been concluded and we have asked the provider for an action plan in response to the concerns found at this assessment.

Systems were in place to investigate abuse allegations and lessons learned. Not all risks had been updated and concerns in relation to the safe management of the refurbishment was noted. Concerns were identified in a number of areas of the environment. Staff training was ongoing and recruitment procedures were in place, the provider confirmed they would review staff file risk assessment for long term staff with gaps in records. The management discussed the ongoing challenges in recruitment and their commitment to reduce agency use. Safe infection control practices were not in place. Action was taken to address shortfalls in the environment, but this was as a result of our findings. A new head housekeeper was in post to support improvements. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Care records required improvements to ensure they all reflected the needs of people living at this service. Partners and management confirmed professionals were visiting the service and involved in people’s care. Staff knew how to maintain people’s dignity and providing good care and providing choice and supporting independence. Improvements were required to ensure the kitchen was clean and safe and people were supported effectively with meals of their choice. There was some evidence about how people were supported to improve health outcomes and hospital passports were developed to support the person in the event of an admission to hospital. The management team talked about how they planned to develop specific hospital passports to support people with a learning disability. Information to confirm appropriate capacity assessments and deprivation of liberty safeguards was not consistently in place.

Professionals were seen in the service on all days we visited, including out of hours. A range of information was on display and accessible to staff. Feedback was sought from people and staff, and you said, we did was on display to demonstrate what the service had done as a result of feedback. Systems were in place to act on concerns and complaints; some positive feedback was seen. People’s end of life needs were mostly considered but 1 persons care record did not reflect their current needs at the end of their life.

Feedback was being obtained but new surveys would benefit from details about what actions they would take as a result of the findings. Audits were ongoing both with the management and senior management, but these did not always demonstrate what actions would be taken as a result of the findings and they failed to identify the concerns we found at this assessment. People and staff were positive about the new manager but said that changes in the service could have been communicated better.