CQC report explained · a nursing home
What the CQC found at Birch Avenue
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2023
Birch Avenue is Rated Good; inspectors found safe, caring support and strong management, with staffing recently increased.
This was an unannounced inspection. One inspector and an Expert by Experience visited on 2 May 2023, with inspection activity ending on 3 May. They spoke with 8 people, 4 relatives and 12 staff, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good overall. Inspectors found people were protected from abuse, risks were assessed, medicines were managed safely, and the home was clean. They also found enough staff to meet people's needs in a timely way.
People appeared comfortable, happy and relaxed. Staff were observed treating people kindly and seeking consent before care. Inspectors found regular audits, good communication and positive feedback about the management team.
Only Safe and Well-led were inspected at this visit. The other key question ratings were carried forward from the previous inspection, so this report does not provide new findings about Effective, Caring or Responsive.
Safe care
Risks were assessed and managed, safeguarding systems were effective, and staff understood how to protect people from harm.
“The provider had effective safeguarding systems in place.” from the report
Staffing
Inspectors found enough staff to support people in a timely way. Staffing had recently increased on each bungalow, and staff said this had made a significant difference.
“There were enough staff available to assist people to meet their needs in a timely way.” from the report
Kind interactions
Staff were seen treating people with care and respect. People appeared comfortable, happy and relaxed in a homely atmosphere.
“Throughout the inspection we observed staff interacting with people in a caring and considerate way.” from the report
Management checks
Managers used audits, spot checks and competence assessments to monitor quality and identify further support or training.
“A number of audits and checks were completed to help ensure continuous learning and improvement.” from the report
Inspectors raised no specific concerns in this report.
- 01How have the recently increased staffing levels been maintained on each bungalow?
- 02How do you check that people continue to receive their medicines at the correct times?
- 03How are people's changing choices, preferences and care needs reviewed?
- 04How can relatives give feedback, and how will the home show what action it has taken?
- 05How do you make sure staff remain confident in supporting people who may lack capacity to make decisions?
This was a focused inspection of Safe and Well-led; the other key question ratings were carried forward from the previous inspection published in 2018. This explanation was written from the published report of 18 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2018
Rated Good; inspectors found safe, kind and personalised care, with only minor improvements needed to the dining room.
This was an unannounced inspection on 4 June 2018. Inspectors spoke with people living at the home, relatives, staff and visiting professionals. They observed care, looked around the building and checked care, medicines, staff and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives said people were safe and well cared for. Inspectors found enough staff, safe medicines systems, trained staff and suitable checks on risks.
Care was respectful and tailored to people's needs. People were supported with food, drinks, health care, activities and daily choices. The home had improved its monitoring of weight, food and fluids since the previous inspection.
The report says the overall rating remained Good and there was no evidence of serious risks or concerns. Inspectors noted that the dining room and the way meals were served needed some improvement.
People felt safe
People living at the home and their relatives said they felt safe. Inspectors found staff understood how to recognise and report abuse.
“People receiving support told us they felt safe living at Birch Avenue.” from the report
Safe medicines
Medicines were stored, given and recorded safely. Nurses' competence was checked regularly, including the handling of controlled medicines.
“There were effective procedures in place for the safe management and administration of medicines.” from the report
Kind and respectful care
Inspectors saw staff supporting people patiently and positively. Staff knew people's preferences and how they wanted their care delivered.
“We saw staff support people in a positive and caring way.” from the report
Personalised support and activities
Care plans reflected individual needs and preferences. People could join in activities, trips and entertainment, and relatives said activities had increased.
“We saw people participated in a range of daily activities both in and outside of the home which were meaningful and promoted independence.” from the report
Improved nutrition monitoring
The home had improved its response to the previous concern about weight loss. Records showed regular weighing and up-to-date monitoring of food and fluids.
“At this inspection, we found improvements had been made to how staff responded to and monitored people's diet and fluid intake needs.” from the report
Strong quality checks
Managers carried out regular audits and checked whether identified improvements had been made. People and relatives also had regular opportunities to give feedback.
“We saw that where audits identified something could be improved, the next audit checked the improvement had been made.” from the report
Dining room presentation
minorInspectors said the dining room and the way meals were served needed some improvement. They noted a lack of coordinated table settings, menus and condiments.
“We saw some improvements with the aesthetics of the dining room and how the meal was served needed to be made.” from the report
- 01What improvements have you made to the dining room and the way meals are served since this inspection?
- 02How will you monitor my relative's weight, food intake and fluid intake if they are at risk of losing weight?
- 03How would you tailor activities and daily routines to my relative's interests, preferences and level of independence?
- 04How do you check that staff remain competent to administer medicines safely?
- 05How do relatives receive updates about changes in a person's health or care needs?
This was an unannounced comprehensive inspection covering all five key questions; the report says the shorter format was used because the overall rating had not changed. This explanation was written from the published report of 29 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Birch Avenue
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- February 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2015Requires improvementstayed Requires improvementSafe: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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