CQC report explained · a nursing home
What the CQC found at Birch Heath Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found gaps in repositioning and fluid records, poor wound-care monitoring, out-of-date care plans and medication errors. They also found that the home was not always following the Mental Capacity Act.
- Effective?
- Good
- This key question was not inspected during this visit. The report says previous ratings were used for key questions that were not inspected.
- Caring?
- Good
- This key question was not inspected during this visit. The report says previous ratings were used for key questions that were not inspected.
- Responsive?
- Good
- This key question was not inspected during this visit. The report says previous ratings were used for key questions that were not inspected.
- Well-led?
- Requires improvement
- Management systems did not reliably identify missed care, medication problems or risks to people's physical health. The provider remained in breach of the good governance regulation.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found risks in care records, wound care, medicines and management systems, although action was taken during the visit.
The inspection was unannounced and took place on 7 and 9 February 2023. Two inspectors spoke with 8 people, 5 relatives and 8 staff. They observed care and reviewed care records, medicine records, staff files and management records.
The inspectors found gaps in records showing people had been repositioned and given enough fluids. Wound care was not always carried out as planned, some care plans were out of date, and one medicine had expired. One person did not receive a prescribed medicine because stock records were incorrect.
The home was also not consistently following the Mental Capacity Act. Its checks and audits did not always identify missed care, medication problems or risks to people's health. The manager acted immediately on several concerns, but inspectors found that the problems had not been fully resolved.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home had the same overall rating at the previous inspection and has been rated Requires Improvement for the last two consecutive inspections.
Recruitment checks
The home carried out checks before employing staff, including agency workers.
“Recruitment processes were robust. Checks were carried out to ensure suitable staff were employed.” from the report
Fire and equipment safety
Inspectors found suitable systems for fire safety and the safe use of equipment.
“Appropriate systems were in place to ensure health and safety, including fire safety was maintained.” from the report
Protection from abuse
People were protected from abuse and allegations were reported to the appropriate agencies.
“People were protected from abuse. Allegations of abuse were reported appropriately to other agencies.” from the report
Positive relationships
People, relatives and staff generally spoke positively about the support and the management team.
“People who use the service felt well supported.” from the report
Open communication
Relatives said they were kept informed when accidents happened.
“They will always call if there's been an accident, they keep us fully updated.” from the report
Risks were not reliably managed
seriousRecords did not always show that people were repositioned or given enough fluids. Wound care was not always completed as required and some care plans were out of date.
“Systems to monitor risk and provide effective support were not robust.” from the report
Medication checks failed
seriousInspectors found an expired medicine and an incorrect stock count. This meant one person did not receive a prescribed medicine.
“When we completed checks on medication, we observed that the date on one medication had expired.” from the report
Management checks were not effective
seriousAudits did not reliably identify missed care, expired medicines or other risks. The provider remained in breach of the good governance regulation.
“Systems were either not in place or robust enough to demonstrate risks to people's physical health were effectively monitored.” from the report
Mental Capacity Act records
needs fixingRecords gave conflicting information about one person's ability to make decisions. The home had not clearly recorded the reasoning or who was involved in some decisions, including a decision about bed rails.
“Decision making for people was not always clearly evidenced.” from the report
Staff availability
needs fixingPeople and relatives gave mixed views about staffing. Some people said they had to wait for help, and inspectors recommended reviewing how staff were deployed.
“We recommend that the manager reviews how staff are deployed across the service, in line with people's dependency levels and the layout of the building.” from the report
- 01How do you now check and record that people are repositioned, given enough fluids and receive their planned wound care?
- 02What changes have been made to prevent expired medicines, incorrect stock counts and missed doses?
- 03How do you make sure care plans are updated promptly when a person's needs change?
- 04How are Mental Capacity Act decisions, best-interest decisions and family or advocate involvement recorded?
- 05What has changed in staff deployment since the inspection, and how do you check that people are not waiting too long for help?
This was a focused inspection of Safe and Well-led; the other key question ratings were not inspected and the overall rating used previous ratings for those areas. This explanation was written from the published report of 25 March 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, May 2021
Rated Requires Improvement; inspectors found caring and effective support, but care records, staffing at busy times and management checks were not reliable enough.
This was an unannounced focused inspection on 9 and 19 April 2021. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, recruitment files and management information, including infection control arrangements.
The home was rated Requires Improvement overall. Safe and well-led were Requires Improvement. Effective and responsive were Good. Inspectors found caring interactions, suitable medicines arrangements, good access to healthcare and person-centred care. However, some risk assessments, care plans and monitoring records were incomplete or out of date.
The home had not made enough improvement since the previous inspection. It remained in breach of Regulation 17 on good governance. The rating had been Requires Improvement for two consecutive inspections.
Kind interactions
Inspectors saw positive, caring interactions. People said staff were kind and understood their likes and dislikes.
“Throughout our inspection we observed positive, caring interactions.” from the report
Medicines
Medicines were stored securely and given by suitably trained staff. Administration records were complete and well maintained.
“Records of administration were well maintained, in line with best practice and completed comprehensively.” from the report
Consent and choice
People were supported to make choices, with best-interest decisions recorded where needed. The previous breach about consent had been resolved.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Healthcare support
People had access to healthcare services, and referrals were made when specialist advice was needed.
“People had access to healthcare services and support; care records showed referrals were made to other health professionals in a timely way when their specialist advice was required.” from the report
Incomplete care records
seriousSome risk assessments and care plans did not reflect people's changing needs. Records of repositioning and other care monitoring had gaps, which meant the home could not reliably show that risks were being managed.
“This placed people at risk of harm. This was a continued breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Staffing at busy times
needs fixingSome people waited for personal care, and some were not supported out of their bedrooms until late morning. The home said it was reviewing how staff were deployed.
“During the inspection, we observed some people were not supported out of their bedrooms until late morning.” from the report
Weak management oversight
needs fixingQuality checks did not always identify or deal with problems promptly. Some staff lacked confidence in the management team and had not received regular supervision.
“A number of records to monitor the care delivered to people were not consistently monitored.” from the report
Domestic staffing and visiting
needs fixingDomestic staffing was lower than usual on several occasions. Inspectors also found one instance where visiting guidance had not initially been followed, although the provider said this had been addressed.
“However, we did identify some shortfalls in the staffing levels of domestic staff on a number of occasions; and one instance where national guidance had not initially been followed for visiting.” from the report
- 01What checks now make sure risk assessments and care plans are updated when a person's needs change?
- 02How do you identify missed repositioning or other care, and how quickly are gaps corrected?
- 03How many staff are usually available during busy morning periods, and what happens if staffing levels fall?
- 04How often do staff receive supervision now, and how do you support staff after the management changes?
- 05What action has been taken to improve domestic staffing and make sure visiting guidance is followed?
This was an unannounced focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and the report used the previous rating for the uninspected key question. This explanation was written from the published report of 27 May 2021 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 Heath Lodge
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementdown from GoodSafe: GoodEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- July 2014
Registered with the Care Quality Commission on 15 July 2014.
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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