# Birchwood Care Services

*Operated by Malvirt Limited.*

Birchwood Care Services is a CQC-regulated home-care agency in Speldhurst.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Requires improvement |
| Safe | Requires improvement |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Requires improvement |

Rating published: 19/05/2023

## Practical info

- Postcode: TN3 0TU
- Registered manager: Napier, Jackie
- Local authority: Kent
- Region: South East
- City: Speldhurst
- Last CQC check: 19/May/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Staff understood MCA principles and gained consent before providing care.
  - Published: 2023-05-25
- Finding
  - Evidence: Infection control practices were followed and PPE was available to staff.
  - Published: 2023-05-25
- Finding
  - Evidence: People and relatives reported the quality of care had improved significantly under the interim manager.
  - Published: 2023-05-25
- Finding
  - Evidence: The interim manager visited every client to obtain feedback, and communication had improved.
  - Published: 2023-05-25
- Finding
  - Evidence: Incidents and accidents were recorded, monitored and reviewed with action taken on identified trends.
  - Published: 2023-05-25
- Finding
  - Evidence: Staff had regular one-to-one supervision meetings and kept training up to date.
  - Published: 2023-05-25
- Finding
  - Evidence: Staff were recruited safely with DBS checks and references obtained before induction.
  - Published: 2023-05-25
- Finding
  - Evidence: People received their medicines safely and staff competencies were checked regularly to ensure best practice.
  - Published: 2023-05-25
- Finding
  - Evidence: Risks to people's health and safety had been assessed and risk assessments implemented with guidance for staff.
  - Published: 2023-05-25
- **leadership** _(moderate)_
  - Evidence: At the time of our inspection there was not a registered manager in post. An application had been received by CQC for a manager to register.
  - Published: 2023-05-25
- **complaints_handling** _(moderate)_
  - Evidence: One person told us they had raised a complaint at the end of 2022, and it had not been investigated.
  - Published: 2023-05-25
- **governance** _(moderate)_
  - Evidence: Some of these had been introduced in March, were now being completed and needed time to be embedded in day-to-day practice.
  - Published: 2023-05-25
- **staffing_levels** _(moderate)_
  - Evidence: The service was reliant on agency carers to cover staff sickness and was actively recruiting to increase their staff levels.
  - Published: 2023-05-25
- **missed_or_late_visits** _(moderate)_
  - Evidence: Some care calls had continued to be cancelled at short notice, relying on relative to provide support, and this was an area for improvement.
  - Published: 2023-05-25
- Finding
  - Evidence: The manager implemented one-to-one supervision meetings and team meetings after identifying they had not been taking place regularly.
  - Published: 2023-02-17
- Finding
  - Evidence: People told us staff supported them in the least restrictive way possible and gained consent before providing care.
  - Published: 2023-02-17
- Finding
  - Evidence: Staff worked with healthcare professionals such as occupational therapists and community nurses.
  - Published: 2023-02-17
- Finding
  - Evidence: Staff understood infection prevention and control measures and had adequate PPE supplies.
  - Published: 2023-02-17
- Finding
  - Evidence: Staff completed training to keep their knowledge up to date, including moving and handling, first aid and catheter care.
  - Published: 2023-02-17
- Finding
  - Evidence: People were supported by staff who had been safely recruited, with DBS checks, employment gap checks and at least two references obtained before induction.
  - Published: 2023-02-17
- **record_keeping** _(minor)_
  - Evidence: When people had prescribed creams to help keep their skin healthy, there were no topical body maps to guide staff to where the creams should be applied.
  - Published: 2023-02-17

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2023-02-17
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-02-17
- Finding
  - Using medicines safely
  - Published: 2023-02-17
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-02-17
- Finding
  - Staffing and recruitment; Learning lessons when things go wrong
  - Published: 2023-02-17

### well_led

- Finding
  - Working in partnership with others
  - Published: 2023-02-17
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2023-02-17
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2023-02-17
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2023-02-17

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-121788906

HomeCare Compass is an independent guide and is not affiliated with the CQC.