Archived: Bircham House

Updated 7 August 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection was undertaken by one inspector and took place on 30 June 2015. The inspection was announced. We gave 24 hours’ notice of the inspection because the service is small and the registered manager is not based in the office. We needed to be sure that they would be in.

Before the inspection we asked the provider to complete and return a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. The provider completed and returned the PIR form to us and we used this information as part of our inspection planning.

We looked at other information that we held about the service including notifications, which are events that happen in the service that the provider is required to inform us about by law.

During the inspection we spoke with five people who used the service and one relative. We spoke with two members of care staff, the care manager and the registered manager of the service. We observed how staff treated and spoke with people.

As part of this inspection we looked at three people’s care plans and care records. We looked at two staff recruitment files, accident and incident reports, complaints and compliments, medicine administration records, quality monitoring and audit information and policies and procedures.

Updated 7 August 2015

This announced inspection took place on the 30 June 2015. This was the first inspection of the service.

Bircham House is registered to provide personal care to people who live in Bircham House extra care scheme. At the time of our inspection 22 people were receiving a personal care service.

The service had a registered manager in post. They had been registered since 2014. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the scheme. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the scheme is run.

The providers’ policy on administration and management of medicines had not been followed by staff which meant that people may not receive their prescribed medicines. Audits that had identified issues in medicine management had not been reviewed to check that the required action had been taken.

People’s needs were assessed, but the information in the care plans was not detailed enough to ensure staff could support people and meet their needs in line with their preferences.

Risks to people’s safety had not always been assessed. Staff had no recorded information on how to deal with incidents should they occur, but they were aware of the actions they should take.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that people who used the service had not had their capacity to make day-to-day decisions formally assessed.

Accidents and incidents had not been recorded and therefore these could not be monitored to prevent further occurrences.

The recruitment process ensured that only suitable staff were employed to provide care to people using the service. There were sufficient staff to meet the needs of people receiving a service.

The provider had quality audits in place to monitor the safety and wellbeing of people using the service. However they had not always ensured that, where issues had been identified, the action plans had been completed.

The risk of harm for people was reduced because staff knew how to recognise and report abuse.

People’s privacy and dignity was respected by all staff. People were aware that there was a complaints procedure in place.

Staff felt supported by the managers and that they were able to discuss any concerns.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.