The Birches - Care Home

The Birches – Care Home is a residential care home. The service accommodates people across four bungalows and two self-contained flats. The bungalows can be accessed via a secure door leading from one to another, but each bungalow was treated as a separate entity. The service is registered to provide support for 31 people who may be living with a learning disability and autism. At the time of our inspection, 27 people lived at the service.

The service is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design and layout. Although the bungalows were all at one location, we found they were separate, and all had their own communal areas. The service was working in line with the principles of Registering the Right Support to ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found

People were happy with the service and complimentary of staff. A relative said, “The service and all the staff from the registered manager, office staff, carers, chef and cleaners are brilliant. We have not met such wonderful people for a long time.”

People felt safe with staff and there was enough staff to meet people’s needs in a timely way. Recruitment, induction and ongoing training processes helped ensure only suitable staff were employed and that they had the required skills and knowledge. Staff were supported by the management team through supervision, appraisals and meetings.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff respected people as individuals, helped people to follow their own routines and to pursue a wide range of hobbies and interests. Staff promoted people’s independence, provided appropriate support and maintained people’s privacy and dignity. People enjoyed the meals and their health and wellbeing was monitored. Referrals were made to healthcare services in a timely manner and staff followed professional advice.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

The registered manager had ensured there was a supportive and positive culture and engaged people in the development of the service, they told us, “People are at the centre of everything we do and every decision we make.” The management team closely monitored the quality of the service and addressed problems promptly.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 11 July 2018) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At the last inspection in May 2017 there were no breaches of regulation. We rated the effective and well-led domains as ‘requires improvement’ which meant the quality rating was 'requires improvement' overall. This is the third consecutive time the service has been rated Requires Improvement. We found quality assurance checks and audits had been improved and staff understood the need to gain consent before care and support was provided. However, the principles of the Mental Capacity Act 2005 were still not followed or implemented in a consistent way.

The service is required to have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. 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 service is run. There was no registered manager at the service, an acting manager had been in place for five days.

The Birches is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates people across four bungalows and two self-contained flats. Three bungalows (Birchdale, Birchwood and Birchwalk) having eight bedrooms and one bungalow (Birchrise) which has four bedrooms. All bungalows could be accessed via a secure door leading from one to another, but each bungalow was treated as a separate entity. There were two self-contained flats, only one was occupied at the time of the inspection. There were 26 people with learning disabilities or autistic spectrum disorder living at the service.

The care service has been developed in some areas in line with the values that underpin Registering the Right Support. (This guidance clarifies the expectation on providers to ensure care homes are focused on person-centred care and developed in line with national policy). We found the bungalows were separate units, even though they were all based at one location. Registering the Right Support values include choice, promotion of independence and inclusion for people living with learning disabilities and autism to ensure they can live as ordinary a life as any citizen. Further work needs to be undertaken once the breaches of regulation have been addressed to ensure the service complies with Registering the Right Support.

During this inspection we found issues with the environment. During our walk round of each bungalow we found issues with the environment which had to be addressed to help to maintain people’s safety. The acting manager took swift action to address the environmental issues we found. However, we recommend that the provider should monitor the environment to make sure it remains safe for people.

We found the administration and management of people's medicines was not always effective to ensure people's medicines were returned, recorded or stored appropriately. We recommend the provider follows good practice guidance in relation to medicine management.

The principles of the Mental Capacity Act 2005 (MCA) were not followed. Decisions were not made in accordance with the MCA. Associated records lacked detail; they were generic and not person-centred. Best interest decisions were not always completed following capacity assessments, which contravened the MCA. This meant that people who used the service had limited choice and control about their lives and experienced unnecessary restrictions.

We found people’s care records were excessive, not easy to follow and staff had made changes to care records without dating or signing entries. It was unclear from people’s care records what care and support people needed to receive or if their needs were being met. A full review, reassessment of people’s records was required, this was planned to take place.

Auditing and checks to maintain and improve standards were not robust and this had meant corrective action to address issues had not always been acted upon in a timely way.

Staff completed training in a variety of subjects. However, it was not clear if staff had taken on board the information provided to them during training. The provider’s training team were about to commence a full review of the staff’s skills and knowledge. Some staff had not received timely supervision in line with the provider’s policy which meant their skills had not been reviewed.

During the inspection we found there was enough staff available to meet people's needs. Infection control measures were in place. Accidents and incidents were being monitored and corrective action was taken to help to prevent any further re-occurrence.

People were supported to eat and drink, where necessary so people’s dietary needs were met.

We saw staff were caring and kind to people and people’s privacy and dignity was respected.

Information was shared in a format that met people’s needs about what the service could provide and about the complaints procedure. Information about local advocacy services was provided to people.

Staff were caring and kind and respected people’s privacy and dignity.

Activities were provided in line with people’s preferences, social events and outings occurred and people were supported to undertake education or go to work if they wished.

Complaints raised were investigated and this information was used to improve the service.

People, using the service, relatives and staff were asked for their views and feedback received was acted upon to help to maintain or improve the service.

The provider and higher management team supported the acting manager. Action was being taken to improve the service provided to people. The provider and staff were working with the local authority and were assisting in safeguarding investigations, if required. The provider had voluntarily stopped admissions to the service until they were satisfied all concerns and issues had been addressed.

The provider was in breach of four regulations from the Health and Social Care Act 2008 (Regulated Activities) 2014. Regulation 11, Need for Consent, 12, Safe Care and Treatment, 17, Good Governance and 18, Staffing.

You can see what action we told the provider to take at the back of the full version of the report.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 service is run.

At the last comprehensive inspection on 19 and 20 January 2017, we rated the service as Requires Improvement overall. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we saw evidence to confirm that the registered provider had taken appropriate action and achieved compliance.

People who used the service were protected from abuse and avoidable harm by staff who had been trained to recognise the signs of potential abuse and knew what actions to take if they suspected abuse had occurred. Staff who had been recruited safely were deployed in suitable numbers to meet the assessed needs of the people who used the service. People’s medicines were managed safely and administered as prescribed. People were cared for in a clean, hygienic and well maintained environment. Staff understood how to minimise the potential for cross contamination and wore personal protective equipment when required.

People were supported by staff who had completed a range of training and nationally recognised qualification in health and social care. Staff told us they received effective levels of support and annual appraisals. People were supported to eat a balanced diet of their choosing. When concerns were identified relevant professionals were contacted for their advice and guidance. The registered manager was aware of the responsibility in relation to the Deprivation of Liberty Safeguards and had submitted applications for a number of people who used the service. However, the principles of the Mental Capacity Act were not followed or applied consistently. After the inspection we received information from a regional director and the registered manager about the actions that would be taken to rectify this.

People were supported by caring staff who knew their needs and preferences for the care and support they required. During our observations it was apparent that caring and supportive relationships had been developed between the staff and the people who used the service. People’s privacy and dignity was respected and promoted. Staff understood the importance of treating private and sensitive information confidentially.

People or their appointed representatives were involved with the initial and on-going planning of their care. People’s levels of independence and strengths and abilities were recorded. People were encouraged to take part in activities and to follow their hobbies and interests. The registered provider displayed their complaints policy within the service and provided it to people at the commencement of the service to ensure it was accessible. We saw evidence to confirm when complaints were received they were investigated and responded to in line with the registered provider’s policy.

Quality assurance systems and processes had been developed to ensure shortfalls were identified and action was taken without delay. People who used the service and their relatives were asked to provide feedback on the service and their opinions were used to make improvements when possible. The registered manager understood and fulfilled their responsibilities to report accidents and incidents as well as other notifiable events to the Care Quality Commission as required.

This inspection of The Birches took place on the 19 and 20 January 2016 and was unannounced. There were 28 people living at the service at the time of this inspection.

When we last inspected the service on 22 April 2016 we found the provider was not meeting the required standards and that they were in breach of regulation 15, premises and equipment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvements were needed to ensure the environment was well-maintained. The registered provider sent us an action plan to tell us the improvements they were going to make. At this inspection we found that the registered provider had not addressed all the concerns we had at our last inspection. We found that sufficient actions had not been taken in relation to maintaining the environment and the service continued to be in breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found four new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to staffing, management of medicines, infection control, maintenance of the environment and the systems for assessing the quality of the service provided. You can see what action we told the provider to take at the back of the full version of the report

The service had a registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found that people's medicines were not always managed safely.

We found at times there were not enough staff to meet the needs of people who used the service during the night. Four care staff were indicated on the rota, however we saw over a three month period prior to this inspection on 13 occasions only three staff had been deployed. The registered provider addressed this during the inspection and gave us assurances that a minimum of four staff would be on duty during the night. We found that some people who used the service had reduced opportunity to access the community due to staffing levels during the day. The registered provider has agreed to re-assess people’s support needs and staffing levels to look at this and make improvements.

We found a number of infection control and maintenance issues that required attention at the service. These included toilet flooring lifting in areas, worn toilet seats, a dirty expel air and significant dirt and dust under radiators.

The registered provider’s quality assurance systems were not effective. They failed to highlight the areas of the service that required improvement and were not used to ensure action was taken to rectify known issues in suitable timescales. There were a number of systems in place in the service but these were not sufficiently robust to identify the shortfalls we found during the inspection. The registered manager and other representatives of the organisation had completed audits to monitor the quality of service and we saw these had highlighted some of the issues identified during our inspection. We saw these had not been addressed in a timely manner. Therefore they were ineffective at driving improvements.

CQC is required to monitor the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection we found where people were receiving covert administration of medicines, there was not always evidence that appropriate decision making processes were in place. Covert administration of medicines may take place when a person regularly refuses their medicine, but they are assessed as lacking the capacity to understand why they need to take the medicine. Covert administration can include the crushing of medicines and adding them to food or drink.

We found that three people had an authorised DoLS in place and two further applications had been made to the local authority; these were pending an outcome. We found that two other people had been assessed as requiring an application for a DoLS; however, these had not been applied for with the authorising body at the time of this inspection. Members of staff we spoke with had a basic awareness of how to gain consent and what restrictions were in place for the people they supported. However, they were less clear in describing the principles of the act and their role with regard to this.

Staff had been recruited safely and appropriate checks were completed prior to them starting work at The Birches. Staff had good knowledge and an understanding of the needs of the people who used the service. Staff received regular supervision and an on-going training programme was provided to assist staff to increase their knowledge and skills.

People living at The Birches said they felt safe and that staff were kind and caring. There were risk assessments in place to help reduce any risks related to people's care and support needs. Staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected.

We observed that staff spoke in a positive way to people and treated them with respect. Staff and people who used the service interacted in a positive way and observations showed good relationships existed between them.

We saw people had personalised care plans in place which included their likes and dislikes. People had regular access to the health and social care professionals involved in their care. People's preferences were acknowledged and staff understood people's likes and dislikes.

We received consistent feedback that there were reduced opportunities for people to partake in activities in the community.

People were given choices at mealtimes and they told us they enjoyed the meals. The atmosphere over the lunchtime period in one of the bungalows was calm and relaxed with conversation taking place. Staff supported people to receive appropriate hydration and nutrition.

People told us they knew how to make a complaint. Information was on display at the service.

The registered manager understood their responsibilities to report accidents, incidents and other notifiable incidents to the CQC as required, and were doing so.

We undertook this unannounced inspection on the 22 April 2016. At the time of the inspection there were 27 people using the service.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 service is run.

Improvements were needed to ensure the environment was well-maintained. This was a breach of Regulation 15(1) (e) of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the back of the report.

We found there were policies and procedures in place to guide staff in how to safeguard people who used the service from harm and abuse. Staff received safeguarding training and knew how to protect people from abuse. Risk assessments were completed to guide staff in how to minimise risks and potential harm. Staff took steps to minimise risks to people’s wellbeing without taking away people’s rights to make decisions.

We found people’s health and nutritional needs were met and they accessed professional advice and treatment from community services when required. Staff kept a log of when people had contact with health professionals in the community. People who used the service received care in a person -centred way, the care plans described their preferences for care and staff followed this guidance.

Positive interactions were observed between staff and the people they cared for. People’s privacy and dignity was respected and staff supported people to be independent and to make their own choices. Staff provided information to people and included them in decisions about their support and care.

We found staff were recruited safely and were employed in sufficient numbers to meet people’s needs. Staff had access to induction, training, supervision and appraisal which supported them to feel skilled and confident when providing care to people.

Medicines were, stored, administered and disposed of safely. Training records showed staff had received training in the safe handling and administration of medicines.

People who used the service were seen to engage in a number of activities both within the service and the local community. They were encouraged to pursue hobbies, social interests and to go on outings. Staff also supported people to maintain relationships with their families and friends.

Menus were varied and staff confirmed choices and alternatives were available for each meal; we observed drinks and snacks were served between meals. People’s weight was monitored and referrals to dieticians made when required.

Staff had received training in legislation such as the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and the Mental Health Act 1983. They were aware of the need to gain consent when delivering care and support and what to do if people lacked capacity to agree to it. When people were assessed by staff as not having the capacity to make their own decisions, meetings were held with relevant others to discuss options and make decisions in the person’s best interest.

People had assessments of their needs and plans of care were produced; these showed us people and their relatives had been involved in the process. We observed people received care that was person-centred. They were able to bring in items from home to make their bedrooms feel homely.

People knew how to make complaints and told us they had no concerns about raising issues with the staff team.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People who used the service told us they were satisfied with the care and support they received. Comments included, 'I feel good about living here, I like it.' Staff were knowledgeable about people's care needs and we observed very positive interactions between staff and people who used the service.

People were supported to be able to eat and drink sufficient amounts to meet their needs and were provided with a choice of suitable and nutritious food and drink. People told us they enjoyed the food provided. Comments included, 'We get plenty of food and we get a good choice.'

There were appropriate arrangements in place to manage medicines.

The environment was suitably designed and clean and tidy but one area was not adequately maintained. We have received written confirmation that the work to improve this area will be completed in a timely manner. There was adequate equipment provided to meet peoples needs.

We found people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People who used the service told us they were satisfied with the care provided and that their needs were met.

We found the environment that was suitably designed and adequately maintained. People told us they liked their rooms and had helped to choose the decor. They told us "It's good living here", "I feel safe here, it's nice and quiet" and "I like living here."

We found staff received appropriate training and support. People told us they liked the staff and they said their needs were met. They told us "The staff are very nice" and "The staff are good, they are all nice."

People were made aware of the complaints system.This was provided in a format that met their needs. People told us they could raise issues if they were not happy.