CQC report explained · a nursing home
What the CQC found at Birchwood Grange Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. There were enough qualified staff, individual risk plans were reviewed, medicines were safely managed and the home was clean.
- Effective?
- Good
- People's needs and choices were assessed, and staff had the training and skills needed. People were supported with food, drinks, healthcare and decisions about their care.
- Caring?
- Good
- Inspectors observed friendly and positive interactions. Staff respected people's privacy, dignity, independence, beliefs, languages and preferences.
- Responsive?
- Good
- Care plans reflected people's preferences and communication needs. There was a varied activities programme, although work was under way to make it more robust and bring back some previous activities.
- Well-led?
- Good
- Inspectors found clear management structures, regular staff involvement and effective audits. The home worked with health and social care professionals and used incidents, complaints and feedback to improve care.
What inspectors found, December 2023
Birchwood Grange Nursing Home is Rated Good; inspectors found safe, kind and well-managed care, but the rating fell from Outstanding.
This was an unannounced inspection on 24 October and 2 November 2023. Inspectors spoke with people living in the home, relatives and staff. They also checked care plans, medicines, staff records, complaints, incidents and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, staff treated them with dignity and care plans gave staff detailed guidance. Inspectors also found enough trained staff, safe medicines practices and good infection control.
The home supported people to make choices, access healthcare, eat and drink well and take part in activities. Inspectors found an open management culture and effective checks to identify and address improvements.
Safe staffing and risk planning
Inspectors found enough qualified and competent staff, including extra one-to-one support where needed. Individual risk plans were reviewed and updated.
“We saw there were enough qualified and competent staff to safely support people.” from the report
Medicines were managed safely
Staff were trained and assessed as competent before giving medicines. Inspectors found no recording discrepancies when checking eight people's medicines.
“We looked at 8 people's medicines and found no discrepancies in the recording of medicines administered.” from the report
Kind and respectful care
People were treated with dignity and staff adapted support to individual needs, including language, food preferences and religious beliefs.
“During the inspection we saw a staff member helping a person to eat their lunch.” from the report
Strong quality checks
The management team used regular audits, incident reviews and staff feedback to identify and address improvements.
“The home had developed a detailed quality monitoring system, which included an internal and external auditing system.” from the report
Call bell response may not always be immediate
minorOne person said staff did not always come straight away when the call bell was used. Inspectors still found staffing levels sufficient and rated Safe Good.
“I have a call bell and staff come maybe not straight away but they do come.” from the report
- 01What activities are now available, and which activities enjoyed before COVID-19 have been brought back?
- 02How do you monitor and respond to call bells, particularly for people who need urgent or frequent help?
- 03How will you assess and review my relative's risks, care needs and staffing support after they move in?
- 04How will you support my relative's communication needs, language, religious beliefs, food preferences and independence?
- 05How will relatives be involved in care reviews, complaints and decisions if my relative cannot make a particular decision?
This was an unannounced inspection that assessed the overall service and all five key questions, including both the premises and the care provided. This explanation was written from the published report of 6 December 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, February 2020
Birchwood Grange Nursing Home was rated Outstanding overall; inspectors found exceptional care, with safety rated Good.
Inspectors visited without warning on 2 and 10 October 2019. They observed care, spoke with people, relatives, staff and health and social care professionals, and reviewed care records, medicines, complaints, incidents, audits and recruitment files.
The home was rated Good for Safe and Outstanding for Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, received medicines safely and had enough trained staff. They also found highly personalised care, strong support for people with dementia, excellent activities and outstanding end of life care.
The overall rating improved from Good at the previous inspection. Effective, Responsive and Well-led improved to Outstanding, while Caring remained Outstanding and Safe remained Good. The report says the service would continue to be monitored through the normal reinspection programme.
Safe medicines systems
Medicines were stored, administered and recorded safely. Staff training and electronic alerts helped reduce the risk of errors, with paper records available if the electronic system failed.
“There were examples of good practice in relation to the management of medicines, including storage, disposal, completion of medicine records (MARs), and administration.” from the report
Dementia support
The environment and care were adapted for people living with dementia. Staff used clear signs, familiar objects and evidence-based approaches to support independence and wellbeing.
“The service was delivering exceptional dementia care, which was shaped around Bradford University dementia care mapping, which is an established approach to achieving and embedding person-centred care for people with dementia” from the report
Kind and inclusive care
People were treated sensitively and their individual identities, beliefs, relationships and communication needs were respected. Families were involved and people were supported to make choices.
“People and their relatives strongly praised the sensitive, considerate and compassionate care provided by the service.” from the report
Activities and reducing loneliness
There was a wide range of activities, including music, trips, animals, technology and community projects. The service also found ways to involve people who did not usually join group activities.
“The activity coordinator was extremely passionate and worked with staff to create activities to ensure people were not isolated.” from the report
End of life care
Inspectors found end of life care to be outstanding. Plans recorded people's wishes and helped staff support people to remain in their preferred place when possible.
“Exceptionally well completed anticipatory care plans were in place, including Do Not Attempt Resuscitation (DNAR) forms where people had agreed to this.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and manage my relative's specific risks, including falls, pressure ulcers, nutrition or swallowing?
- 02How do you check that medicines are given at the right time, and what happens if the electronic medicines system is unavailable?
- 03How will you involve my relative and our family in creating and reviewing a personalised care plan?
- 04What activities would suit my relative's interests, culture, communication needs and level of dementia?
- 05How would you record and follow my relative's wishes about end of life care and their preferred place of care?
This was an unannounced comprehensive inspection covering the premises, care and all five CQC question areas; the previous ratings were also reviewed. This explanation was written from the published report of 4 February 2020 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Birchwood Grange Nursing Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- December 2023Goodcurrent ratingdown from OutstandingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Birchwood Grange Nursing Home →
- February 2020Outstandingup from GoodSafe: GoodEffective: OutstandingCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
Read what inspectors found at Birchwood Grange Nursing Home →
- February 2017GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- November 2014
Registered with the Care Quality Commission on 13 November 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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