Archived: Birchwood Retirement Home

We found the following examples of good practice.

• There was a strict procedure in place for visitors. Staff took temperatures, and provided Personal Protective Equipment (PPE). The national Track and Trace system was also in place. There was a protocol for relatives to adhere to, with set visiting times, and only one designated visitor. Visitors and people were socially distanced.

• There was a 'Covid-19 information Board’ which contained current information and guidance. This ensured all staff and any visitors had access to up to date information.

• PPE in use complied with current guidance with masks and visors in evidence. Gloves and aprons were frequently changed and regular hand washing was observed.

• The service was cleaned with chloride cleaning solution to reduce the risk of spread of infection. The service was well-maintained. Good use had been made of the Infection Prevention and Control (IPC) grant to replace worn flooring in the dining room, to upgrade the laundry, and included easily washable walls and surfaces.

• The use of smaller communal rooms was helpful in managing social distancing. The home was warm with windows open and good air flow throughout.

Further information is in the detailed findings below.

We inspected the home on 1 and 6 November 2017. The inspection was unannounced. There were 16 people living in the home on the first day of our inspection.

The home had a registered manager in post. A registered manager is a person who has registered with CQC to manage the service. Like registered providers (‘the provider’) 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.

In August 2016 we conducted a first comprehensive inspection of the home. We rated it as Requires Improvement, reflecting shortfalls in a number of areas.

On this inspection we were pleased to find the provider had taken action to address these issues and the rating is now Good.

There were sufficient staff to keep people safe and meet their care and support needs. Staff worked well together in a mutually supportive way and communicated effectively, internally and externally. Training and supervision systems were in place to provide staff with the knowledge and skills they required to meet people’s needs effectively. Staff provided end of life care in a sensitive and person-centred way.

There was a friendly, relaxed atmosphere and staff were kind and attentive in their approach. People were provided with food and drink of good quality that met their individual needs and preferences. The physical environment and facilities in the home generally reflected people’s requirements. People were provided with physical and mental stimulation appropriate to their needs.

People’s medicines were managed safely and staff worked closely with local healthcare services to ensure people had access to any specialist support they required. Systems were in place to ensure effective infection prevention and control.

The registered manager had worked hard to address the issues for improvement identified at our last inspection. He was well liked and well known to everyone connected to the home. A range of audits was in place to monitor the quality and safety of service provision. People’s individual risk assessments were reviewed and updated to take account of changes in their needs. Staff knew how to recognise and report any concerns to keep people safe from harm. There was evidence of organisational learning from significant incidents and events. Any concerns or complaints were handled effectively.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection, no-one living in the home was subject to a DoLS authorisation. Staff understood the principles of the MCA and demonstrated their awareness of the need to obtain consent before providing care or support to people. Decisions that staff had made as being in people’s best interests were correctly recorded.

We inspected the home on 25 August and 1 September 2016. The first day of our inspection was unannounced.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers (the ‘provider’) 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.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection, living in the home was subject to a DoLS authorisation and the provider had no applications pending.

We found a number of areas where improvement was needed to ensure people were provided with safe, effective care that met their needs.

Action was needed to improve the cleanliness of the some of the communal areas of the home. Laundry arrangements also required improvement to reduce risks to people’s health and safety.

The arrangements for the storage and disposal of people’s medicines were unsafe and were not in line with good practice and national guidance.

The provision of communal activities was, at times, unstructured and haphazard which meant some people lacked sufficient stimulation and occupation.

The use of best interests decision making processes was inconsistent meaning some people may have been deprived of their legal rights under the MCA. The provider’s audit and monitoring systems were also not consistently effective.

In other areas the provider was meeting people’s needs effectively.

Staff knew how to recognise signs of potential abuse and how to report any concerns.

Staff worked closely with local healthcare services to ensure people had access to specialist support whenever this was required. People were provided with food and drink of good quality that met their individual needs and preferences.

There was a warm, homely atmosphere and staff had a welcoming approach to visitors. Staff knew people as individuals and provided care in a kind and patient way. There were sufficient staff to meet people’s care needs and staff worked together in a friendly and supportive way. The provider supported staff to undertake their core training requirements and encouraged them to study for further qualifications.

The registered manager demonstrated an extremely open and responsive management style, providing a positive role model for other staff.