CQC report explained · a residential care home
What the CQC found at The Birches
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
The Birches was rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced inspection on 24 August 2022. One inspector spoke with a person using the home, two relatives and nine staff. They reviewed care records, medicines records, staff recruitment and supervision files, and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, medicines were managed safely, staffing levels were sufficient and infection control measures were in place.
People were involved in their care planning and daily choices. Staff supported people with mental health needs to stay independent, follow their interests, eat well and access healthcare. Relatives said they were kept informed.
The previous rating was Requires Improvement, published in May 2019. The report says improvements had been made and the home was no longer in breach of regulations.
Safe medicines management
Medicines were administered by trained staff, with regular checks of stock, records and staff practice. Guidance was in place for medicines given when needed.
“Regular checks were completed of the medication stock and records, we reviewed these records and we found that people had their medication administered safely” from the report
Personalised support
Care plans recorded people's choices, preferences and decisions. Staff adjusted support when people's needs changed and helped people work towards their goals.
“There was a positive, person-centred approach to the delivery of people's care.” from the report
Kind and respectful staff
People and relatives spoke positively about how staff treated them. Staff respected privacy and encouraged people to do things for themselves.
“We found staff were respectful and maintained people's dignity, privacy and independence.” from the report
Strong oversight
The provider and management team used regular audits to check the service. Inspectors found that identified improvements were acted on.
“We found the systems in place to be robust and identified areas for improvement which were then actioned.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and support my relative's particular mental health needs, including what staff should do if they become distressed?
- 02How often will my relative's care plan and risk assessments be reviewed, and how will I be involved?
- 03Which staff will support my relative, and how do you make sure there are enough familiar staff available?
- 04How do you check that medicines are given correctly, including medicines that are taken only when needed?
- 05What training and support would staff receive if my relative needed end of life care?
This was an unannounced inspection of all five key questions, including infection prevention and control; no one was receiving end of life care during the visit. This explanation was written from the published report of 8 October 2022 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 2019
Rated Requires Improvement; inspectors found kind, effective care, but medicines records and management checks were not reliable enough.
The inspection was unannounced and took place on 17 April 2019. One inspector reviewed care records, staff records and the home's quality checks. They spoke with the acting manager, three care staff and one person living there.
People were generally safe, treated kindly and supported to make choices. Staff knew people well, provided personalised care and helped people take part in activities and access the community. Health care was managed well.
The inspectors found problems with medicine records and checks. Some controlled drug records did not have two staff signatures, medicine balances were not always recorded, and records did not always show how much as-required medicine had been given.
The overall rating was Requires Improvement, down from Good at the previous inspection in October 2016. Safe and Well-led were rated Requires Improvement. Effective, Caring and Responsive were rated Good.
Kind and respectful staff
Staff treated people with dignity and compassion. They knew people's personalities, preferences and care needs.
“Staff were kind and caring and people were treated with dignity and respect.” from the report
Personalised support
Care plans reflected people's wishes and routines. People were supported to make choices and develop everyday living skills.
“Care plans were person centred; they took account of people's likes, dislikes, wishes and preferences in relation to their daily routines.” from the report
Good health support
Staff understood people's health needs and followed advice from health professionals. People were supported to attend medical appointments.
“Advice provided by healthcare professionals was followed by staff which ensured people were supported to maintain their health and wellbeing.” from the report
Activities and community access
People took part in activities such as baking and caring for animals. Staff also supported people to go out into the local community.
“This included baking, tending to guinea pigs and staff supporting people on trips out from the home to access the local community.” from the report
Medicine records
seriousThe home could not always show that medicine stocks were correct. Controlled drug signatures, returned medicine balances and as-required medicine records were incomplete.
“Medicine administration records (MAR) did not always record the number of 'as required' (PRN) administered.” from the report
Checks did not find problems
seriousThe home's audits did not identify the medicine recording issues found by the inspector. Quality monitoring therefore did not reliably lead to improvements.
“Audits did not identify any of the issues highlighted by our inspection.” from the report
Maintenance issues
needs fixingSome maintenance problems reported to the provider in 2018 had still not been addressed when inspectors visited.
“Maintenance issues reported to the provider in 2018 had not been addressed.” from the report
Food allergen records
needs fixingThe provider knew about people's allergies but had not assessed or recorded the allergens in the food provided.
“Despite being aware of people's allergies, the provider did not assess or record the allergens present in the food provided.” from the report
No registered manager
needs fixingThe previous registered manager had left. A senior staff member was acting as manager while recruitment was in progress.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01What changes have you made to medicine administration records, controlled drug signatures and records of returned medicines?
- 02How do you now check that medicine audits identify and correct recording errors?
- 03Has a registered manager been appointed since this inspection, and who is responsible for the home in the meantime?
- 04Have the maintenance issues reported in 2018 been dealt with, and how are outstanding repairs tracked?
- 05How are food allergens now assessed and recorded for people living in the home?
This was an unannounced comprehensive inspection covering all five CQC questions, and the previous overall rating was Good in October 2016. This explanation was written from the published report of 16 May 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.
Every inspection of The Birches
3 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- March 2012
Registered with the Care Quality Commission on 30 March 2012.
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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62 live-in carers within about an hour of Derbyshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,010 to £1,260 a week. 51 can care for a couple. 12 years' experience on average.
“Ernest is an amazing professional carer who delivers care from the heart.”
“We particularly appreciate the companionship Dawn gives in the evenings when she plays cards and Scrabble with my mother.”
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