Birch Avenue

“We found 2 breaches of regulation relating to safe care and treatment and good governance. The service was previously rated good in 2023. The service is now rated requires improvement.”

“The service were aware of shortfalls in people’s care records and were currently working with the local authority to improve safe care and treatment for people. However, we found the service did not always ensure risks to people were assessed and managed. Care plans lacked guidance in relation to risks associated with people’s diagnosed health conditions. There was a lack of robust assessment of people’s needs. The service did not always provide evidence-based care and treatment for people, such as meaningful activities and did not review clinical monitoring tools in a timely manner.”

“There was a lack of effective governance, oversight and monitoring of the service and governance processes did not identify the issues we found during this assessment. Quality assurance systems and processes were not effectively implemented to ensure safety and drive improvements. There was a lack of oversight and knowledge from leaders at all levels around roles, responsibilities and accountability to enable good governance.”

“However, we found staff knew people well, spoke positively about their roles and felt supported by the management team. Our observations of care provided were positive, and people and their relatives told us they were satisfied with the service. The service responded positively to the shortfalls identified. We asked the service for an action plan in response to the concerns found at this assessment.”