30 June 2015
During a routine inspection
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.