CQC report explained · a nursing home
What the CQC found at Birchwood Grove
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found enough staff, good infection control and systems for managing risks. However, some medicines and drink thickener were not securely managed, checks were incomplete, and some electronic risk records lacked details or guidance.
- Effective?
- Good
- People's needs were assessed and reviewed, staff were trained, and people received suitable food and healthcare support. Some staff had not always received training for specific diagnoses, and some electronic records did not reflect the information staff gave inspectors.
- Caring?
- Good
- Staff were kind, patient and respectful. People were offered choices, their privacy and dignity were protected, and relatives were welcomed.
- Responsive?
- Good
- Care plans were personalised and people took part in activities and decisions about their care. Some information had not been fully transferred to electronic care plans, and menu information was not always visible to people with memory difficulties.
- Well-led?
- Good
- People, relatives and staff were positive about the management. Managers were accessible, involved people in the home, monitored quality and acted on issues identified during the inspection.
What inspectors found, July 2019
Rated Good overall, but inspectors found that medicines and some care records were not always managed safely.
This was an unannounced inspection of the home. Inspectors spoke with people living there, relatives, staff and health and social care professionals. They observed care and checked care records, medicines, audits and safety information.
People and relatives said they felt safe and were happy with the home. Staff were described as kind and caring. There were enough staff, people received personalised care, and the home worked well with health professionals.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, as some medicines were not stored or monitored properly and electronic care records did not always contain all the needed information.
Kind and respectful staff
People and relatives described staff positively. Inspectors saw respectful relationships and staff protecting people's privacy and dignity.
“People were supported by kind, caring and patient staff.” from the report
Enough staff
People and staff said staffing levels were sufficient. Inspectors saw call bells answered quickly and people taking part in activities.
“People told us, and we saw, there were enough staff to meet their needs.” from the report
Personalised care
Care plans reflected people's individual needs and wishes. Staff knew people well and adapted support when needs changed.
“People's care plans were personalised to their individual needs and wishes.” from the report
Good partnership working
The home worked with health and social care professionals, who were contacted when people's health changed.
“Staff and the management worked with a range of local health and social care professionals to improve the care people received.” from the report
Responsive management
Managers acted when inspectors raised concerns and had systems to monitor care quality and respond to complaints.
“During the inspection, when any concerns were raised the management were proactive in responding to them.” from the report
Medicine storage and checks
seriousSome topical creams were unsecured, and checks on storage temperatures and expiry dates were missing. Medicine patches were not monitored properly, and blood sugar machines were not being calibrated.
“Systems were not in place to monitor the rotation of medicine patches which could lead to a potential overdose due to thinning skin.” from the report
Drink thickener was not secure
seriousThickening powder was not stored securely, creating a risk for people who could choke or aspirate. Managers found a new secure storage place during the inspection.
“People were at risk of choking or aspiration because drink thickening powder was not being stored securely.” from the report
Incomplete electronic care records
needs fixingSome information and guidance from paper records had not been fully transferred to the new electronic care plans. Paper records were still available, and managers planned improvements.
“There were gaps present in daily monitoring records or missing guidance for staff.” from the report
Some food was left to get cold
minorOn the first inspection day, some meals were left in bedrooms while other people were supported. Managers resolved this by the second day.
“On the first day of inspection some food was taken to people in their bedrooms and left getting cold whilst others were supported.” from the report
Information about lunch
minorSome people with memory difficulties could not easily see the menu boards, so they were not always told what lunch choices were available.
“There were occasions information was not always shared in an accessible way for people who had memory difficulties.” from the report
- 01What changes have been made to secure topical creams and drink thickener?
- 02How are medicine patches, medicine storage temperatures and expiry dates now checked?
- 03How often are blood sugar checking machines calibrated, and where is this recorded?
- 04Have all paper care plans and risk guidance now been transferred accurately to the electronic system?
- 05How are menu choices made clear to people with memory difficulties?
This was an unannounced inspection covering all five CQC questions, although the report gives different inspection dates in its front section and detailed section. This explanation was written from the published report of 4 July 2019 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, December 2016
Rated Good overall, but Safe Requires Improvement because inspectors found risks in how some medicines were stored and recorded.
Inspectors visited the home without warning on 5 December 2016. They spoke with people living there, relatives, staff and healthcare professionals. They also checked care records, medicine records, staff records and quality checks, and observed care, meals and medicines being given.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. Inspectors found kind staff, personalised care, suitable activities, good health support and strong management systems.
Safe was rated Requires Improvement. Inspectors found that some medicines were left unattended. Records and guidance for medicines given only when needed were not always clear or complete. The home had improved several issues found at the previous inspection, including care records, repositioning checks and activities for people living with dementia.
Improvements since the last inspection
The home had acted on several earlier concerns. Inspectors found better moving and positioning records, regular checks for people unable to use call bells, and records for creams and repositioning.
“At this inspection it was evident that improvements had been made.” from the report
Kind and respectful care
Staff knew people well, respected their privacy and choices, and developed positive relationships with them.
“There was a friendly, homely and relaxed atmosphere and people were cared for by staff that were kind and caring.” from the report
Activities suited to individuals
The home had improved activities and offered different options, including reminiscence, crafts, music and one-to-one activities for people who preferred to stay in their rooms.
“For people who spent time in their rooms or who preferred more one to one time with staff, innovative activities had been introduced” from the report
Positive management
Inspectors found approachable leaders and regular checks on the quality of care. Feedback was encouraged and used to make changes.
“There were good systems and processes in place to ensure that the home was able to operate effectively” from the report
Medicines were not always secure
seriousSome medicines were left unattended while staff collected water. This created a risk that the wrong person could access them.
“some medicines were left on top of the medicines trolley, unattended, whilst the registered nurse collected fresh water for people to take their medicines.” from the report
Incomplete medicines guidance and records
seriousThere was not enough person-specific guidance for medicines given only when needed. On one occasion, the time a medicine was given was not recorded, creating a risk of an incorrect dose or a delay.
“there were no guidelines that related to individual people for staff to follow in relation to 'as and when required' medicines.” from the report
- 01What changes have been made to ensure medicines are never left unattended?
- 02How do staff know when to give each person's medicines that are prescribed only when needed?
- 03How are the time and outcome of every medicine dose checked and recorded?
- 04What monitoring is now carried out to make sure medicine records and storage remain safe?
- 05What activities would be available for my relative, based on their interests and communication needs?
This was an unannounced comprehensive inspection covering all five key questions; the report also records that the home had improved concerns found at the previous inspection. This explanation was written from the published report of 21 December 2016 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 Birchwood Grove
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- July 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2014
Registered with the Care Quality Commission on 1 April 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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