Birch Tree Manor

Birch Tree Manor is a 'care home' providing accommodation, nursing and personal care for up to 62 older people; some of whom lived with dementia. At the time of the inspection 57 people were living at the home.

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

People were not fully protected from the spread of infection. COVID 19 weekly testing regimes were not always carried out in line with government guidance. Parts of the environment were not kept clean and hygienic and staff did not always wear the correct level of PPE. These matters were addressed at the inspection.

People told us they were happy with the care they received and said they felt safe living at the home. One person said, " Everyone is really nice." People living at the home were comfortable with staff. Staff spent time chatting with people and supporting them when they became distressed.

People were protected from abuse because staff understood what was meant by abuse and the correct procedures to follow if they had any concerns about people’s safety. People received their medicines as prescribed and staff had clear information about how people liked to be supported with their medicines. Staff were knowledgeable about people's health needs and the provider had sought support from other health professionals as appropriate to support people's needs.

Risks were not always fully assessed, monitored and reviewed. Risks such as choking, and weight monitoring was not always monitored appropriately. Some key information in people’s care records about the management of risk was not accurate.

Staffing levels were appropriate and matched the dependency tool being used to match the needs of people at the home. The home used a moderate volume of agency staff. The provider assured us that they were continuously working to recruit more permanent staff. Staff received training and support to enable them to effectively meet the needs of the people they supported.

Rating at last inspection

The last rating for this service was requires Improvement (published 23 December 2020).

Why we inspected

We carried out an unannounced focused inspection of this service on 1 November 2021 following a number of concerns relating to COVID-19 testing and intelligence gathered through various sources and our system. This report only covers our findings in relation to the Key Questions of Safe and Well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Our report is only based on the findings in those areas at this inspection. The ratings from the previous comprehensive inspection for the caring, effective and responsive key questions were not looked at during this visit. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used to calculate the overall rating at this inspection.

The overall rating for the service has remained 'requires improvement'. This is based on the findings at this inspection. We found evidence that the provider still needs to make improvements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Birch Tree Manor on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

At this inspection we have identified breaches in relation to safe care. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Birch Tree Manor is a care home providing personal and nursing care to 51 people aged 65 and over at the time of the inspection. The service is purpose built and the accommodation is in three units over two floors. Each of the units support people living with different conditions such as dementia and nursing needs. The service can support up to 62 people.

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

Care plans and risk assessments were in place that reflected the needs of the people. Medicines were managed safely and staff who administered medication had had their competencies checked.

People looked happy, healthy and responded positively when staff approached them or spoke with them. The atmosphere was friendly and peaceful.

Staff wore personal protective equipment (PPE) and clear guidance was in place regarding keeping people safe from the risks associated with the coronavirus pandemic. Staff were recruited safely and there were enough of them to meet people's needs.

Quality systems were robust and staffing structure and accountabilities were clear. Accidents and incidents were managed appropriately, and referrals were made to other professionals in a timely manner when people living in the home needed their support. The deputy manager notified CQC of significant incidents when it was appropriate.

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

Rating at last inspection

The last rating for this service was requires improvement (published 04 February 2020). The service remains rated requires improvement. This is due to only safe and well-led domains being inspected.

Why we inspected

We received concerns in relation to the governance of the home. As a result, we undertook a focused inspection to review the key questions safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Our report is only based on the findings in those areas reviewed at this inspection. The ratings from the previous comprehensive inspection for the Effective, Caring and Responsive key questions were not looked at on this occasion. Ratings from the previous comprehensive inspection for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service remains requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Birch Tree Manor on our website at www.cqc.org.uk.

Follow up

We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Birch Tree Manor is a care home providing personal and nursing care for up to 62 older people. The service is purpose built and the accommodation is in three units over two floors. Each of the units support people living with different conditions such as dementia and nursing needs. At the time of the inspection there were 53 people living at the service.

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

At the last inspection, we found that Birch Tree Manor was not providing safe care for people and was poorly led and managed.

At this inspection, although we found significant improvements had been made, the service required further time to embed safe and effective practices and to demonstrate consistency of those practices.

People’s consent and capacity were not always being managed in the most appropriate way. This meant that people were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always supported this practice.

People’s end of life wishes was not recorded in sufficient detail in their care plans. We have made a recommendation about the recording of people’s wishes for the future.

Staff had received additional training in safeguarding and were knowledgeable about how to recognise and report on any abusive practices. This helped keep people safe from harm.

Safer recruitment practices were in place for staff. The service ensured that any potential employees were safe to work with vulnerable people.

We observed positive and warm interactions between staff and people living at the service. It was clear that staff knew the needs of the people they supported well.

The service employed a full time activities co-ordinator who facilitated and delivered meaningful activities to people. People were encouraged and supported to be a part of both their local and wider community.

Medicines were managed in a safe way. Infection prevention control practices were practised by staff and the service appeared clean and well maintained.

Appropriate governance systems were in place which helped to monitor the safety and quality of care being provided.

Risks to people were assessed to help keep people safe from personal and environmental risks.

Since the last inspection, a new registered manager had been appointed. People, relatives and staff spoke positively about the registered manager.

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 Inadequate (published September 2019) 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 that although significant improvements had been made, the provider remained in breach of regulation, as a longer period was required to demonstrate continuity of good practice.

This service has been in Special Measures since September 2019. During this inspection, the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

The inspection was prompted in part by notification of a specific incident. Following which a person using the service allegedly sustained abuse. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about both the management of safeguarding incidents and recruitment processes.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe section of this full report.

We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Birch Tree Manor on our website at www.cqc.org.uk.

Enforcement

At this inspection, the provider remained in breach of regulation in relation to how people’s capacity and consent were being managed.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will monitor the progress of the registered provider's action plan to mitigate risk and improve practices. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Birch Tree Manor service is a residential care home providing personal and nursing care to 62 people. The home is a purpose built modern detached building set over two floors. The home supports people who have needs associated with ageing or are living with a dementia related illness. At the time of our inspection 62 people were living at the home.

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

At our last inspection we found the service had met a wide range of concerns found at previous inspections. We did however find that there were issues with how people’s capacity and consent were being managed. At this inspection we found the service provided to people had again deteriorated. Birch Tree Manor was not providing safe care for people and continued to be poorly led and managed.

People were not always protected from abuse as appropriate procedures were not always followed. Staff were not identifying potential abuse and incident reporting was poorly managed. This put people at unnecessary risk of harm.

Where people were at risk of harm insufficient action had been taken to ensure the risks were fully assessed and preventive actions understood by staff. These were both with personal risks, such as the risk of people falling, and risks in the environment.

Medicines were not always managed safely. Infection prevention and control practices were not always followed. The home was not satisfactorily clean. This meant the provider failed to ensure people were protected against the spread of infectious diseases.

The provider and registered manager did not have a clear strategy for the care of people living with dementia. Staff had not received training on how to support such people and had limited coping strategies for managing behaviours associated with dementia.

The provider and registered manager failed to implement robust governance systems to identify and address shortfalls, risks and unsafe practices.

We have made a recommendation about improving how complaints are handled.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We have made a recommendation about helping people with limited verbal communication to express their wishes.

People told us that the staff were caring towards them. hey told us of interesting activities and events put on by the home and how they enjoyed a range of activities led by the activities coordinator. People’s relatives told us that they were always made to feel welcome at the home.

People in the home and relatives told us the registered manager was friendly and approachable.

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 26 July 2018) and there was a breach relating to gaining people’s consent. The provider completed an action plan after the last inspection to show what they would do and by when to improve. However, at this inspection the service had deteriorated to an overall inadequate rating. The provider was still in breach of this regulation, and we found further breaches of the regulations. The service had been rated as requires improvement for the last three inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to person-centred care, safeguarding services users from abuse and improper treatment, the need for consent, safe care and treatment, good governance and staffing.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have concluded.

Follow up

The provider set us an action plan immediately after the inspection to mitigate the risks.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this time frame and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Birch Tree Manor is a purpose built modern detached building in a residential area

of Port Sunlight, Wirral. The building is over two floors with well-kept courtyard style gardens. The home is registered to provide care and accommodation for up to 62 people. At the time of our inspection 56 people were living at the home.

Birch Tree Manor 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 service required and 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. The registered manager had been in place since October 2015.

At our previous inspection in January 2017 we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the provider had not ensured that the administration of medication was consistently safe. We also found a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the provider had not ensured there was appropriate support, professional development and supervision for staff. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve in our key questions areas of Safe, Effective and Well Led.

During this inspection we found that there had been improvements in the administration of people’s medication and this was now safe. There had also been improvements in the support and supervision provided to staff members. The service was no longer in breach of Regulation 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did find during this inspection a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as people’s consent was not effectively sought. When people lacked the capacity to consent, the registered manager did not always act in accordance with the Mental Capacity Act 2005. This meant the key question areas of Effective and Well Led were rated as ‘requires improvement’ and therefore the overall rating for the service remains ‘requires improvement’. You can see what action we told the provider to take at the back of the full version of the report.

Information regarding who had a current Deprivation of Liberty Safeguard (DoLS) in place, for whom one had been applied and the rationale for the application to deprive a person of their liberty was unclear. The registered manager was initially unable to tell us who had a DoLS in place, this was also unclear when looking at people’s care files.

When people were faced with decisions it was unclear how they had been involved in this decision. How they had been supported to make or contribute to the decision or how it was demonstrated that the decision made was in the person’s best interests.

There were multiple documents that were used to assess a person’s capacity. However, these were unclear as they did not state the decision to be made, demonstrate what information had been presented to a person or what help and support had been available to aid a person making a decision. These documents showed that in these cases the assessing of a person’s capacity was not effective but was a paperwork exercise that was completed when people’s care plans were written.

During the review and auditing of people’s care files, the home did not use information in people’s daily care records. This meant that there was a risk that opportunities for learning and improving the quality of people’s care based on daily observations were being lost.

People told us that they were happy living at the home. One person told us, “I’m very happy here.” Another person said, “The staff have been nice. A lot of them are very pleasant.” A third person told us, “I feel safe here, if I have any problems I talk to the staff.”

People’s relatives told us that they had confidence in the home, the staff and the registered manager. One relative told us about their family member, “He’s totally safe.” Another person’s relative explained, “It’s brilliant here, she’s safe and it’s lovely, they are so lovely. I have seen staff sit and hold her hand. I have peace of mind that she is safe. It’s worth it. When you know she is safe, it is such a relief.” One person told us during their lunch, “I’ve made a lot of friends here.”

There was staff training, systems and processes in place that helped ensure people were safe. People’s medication was administered safely and regular audits of medication took place. The environment was safe and regular checks of its safety were made. Staff were recruited in a way that helped ensure they were safe to work with vulnerable adults and they also received training in safeguarding vulnerable adults. Assessments of the risks in people’s care took place and any accidents or incidents that occurred were reviewed for future learning and prevention.

There was enough staff at the home to meet people’s care needs and people and their relatives told us their needs were attended to in a timely manner. People told us that the staff were caring towards them. People’s relatives told us that they were always made to feel welcome at the home. People’s relatives praised the home’s environment and the bedrooms. One relative told us, “Room is clean and tidy. It’s very nice. They have put a bird table outside the window. He has personalised his room with personal effects.” Another relative said, “When you come in the room is always lovely, they water her plants for her.”

Staff told us that they were happy in their roles and felt well supported. There was appropriate training and support in place to enable staff to be effective in their role.

People and their relatives told us that they were well supported with their healthcare. One person told us, “They get the GP for me if he’s needed.” One person’s relative said, “If there is anything wrong health wise, it gets sorted quickly with the doctors.” We saw that the home worked alongside health and social care professionals.

People told us that they enjoyed the food provided at the home and there was a good variety. People’s nutritional needs were monitored and met.

Each person had their own care file, we saw that these were individualised to each person and their support needs. These were completed to a reasonable standard and provided necessary information on how to support the person safely according to their needs and preferences.

People and their relatives praised the quality, variety and personal attention provided during the activities available to people both inside the home and in the community.

The manager knew people living at the home and was kind in her interactions with them. People’s relatives expressed confidence in the registered manager and told us they found her approachable. People’s relatives told us that any concerns raised with the registered manager were dealt with quickly.

Accommodation is in 62 single occupancy bedrooms, each bedroom has en-suite toilet facilities. The upper floor is accessible by a staircase and a passenger lift. There are also additional communal toilets, shower rooms and bathrooms on each floor.

The home required and 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.

During our inspection we found breaches of regulation 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the administration of medication was not consistently effective and safe. Also there was not appropriate support, professional development and supervision to enable staff to carry out their duties they are employed to perform.

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

The management of people’s medicine was not consistently safe. One person’s medication had been out of stock for two days, this meant the person had missed some doses of their prescribed medication. When we checked a sample of people’s medication, we found that the amount of some people’s medication left in the medication stocks did not match what had been administered. This meant that medication administration and recording had not been consistently accurate.

The supervision system in place to support staff in their development and to ensure that staff had the skills and knowledge necessary for their role was not being used effectively. For example some nursing staff not clearly explain to us their responsibilities in safeguarding vulnerable adults. This meant that they may not know how to react in order to keep people safe.

People’s relatives told us that there were not always enough staff on duty at the home. During our visit we did not see anybody waiting for care. There were indications however that staff were rushed and under pressure in meeting people’s needs and performing duties in a timely manner. For example some staff told us they had been too busy to complete records in a timely manner and some people’s family members told us they had witnessed people waiting for care.

People and their relatives told us that they felt safe living at the home. One family member when asked if their loved one was safe said, “Absolutely, there is no question about it”. Staff were knowledgeable about the signs to look out for should they suspect abuse had occurred. However they lacked knowledge about how to report this to the relevant authorities.

We saw that any incidents and accidents which had occurred at the home were recorded by staff and these records were reviewed monthly by the registered manager. Safeguarding referrals to the local authority and appropriate notifications to the CQC were made by the registered manager.

The environment of the home was clean, well maintained and safe. Appropriate checks had been made by competent individuals of the homes equipment and services to ensure they were safe.

We found from looking at staff recruitment records that staff had been recruited safely with the relevant checks being completed prior to their employment.

We found that the service operated within the principles of the Mental Capacity Act 2005. Appropriate referrals had been made to the local authority for people who would benefit from a Deprivation of Liberty Safeguard to keep them safe. This was done after completing an assessment of the person’s capacity.

A lot of thought, research and creativity had gone into the design of the home’s environment. It was a stimulating and interesting environment for the people who lived at the home. The environment was homely and not clinical with areas of interest such as a bus stop, post box, a bar, beauty salon and outdoor courtyard areas.

People told us they liked the food and there had been recent improvements in the quality of the food provided at the home. We were told that there was now more “Home cooking”, there was always choice and people’s needs and preferences were catered for.

Care plans were person centred and were mostly effective in ensuring people received the care they needed. The deputy manager was in the process of reviewing and changing the format of each person’s care plan and we saw that half of people’s plans had been reformatted in this way. Two visiting GP’s and people’s relatives told us that people were well supported with their health needs and they had confidence in the staff at the home in this regard.

There was a range of meaningful home and community based activities available to people who lived at the home. The activities were for people with a range of abilities, preferences and support needs. This included opportunities for people to express themselves spiritually, develop their interests and be part of their local community. Everybody we spoke with praised the activities at the home.

The registered manager was well known and had positive relationships with the people who lived at the home and their relatives. The registered manager told us it was important that people socialised and had meaningful activities to participate in and that the home provided a nice homely environment.

People’s relatives told us that they had confidence in the registered manager and felt comfortable going to them with any concerns or complaints. They told us the registered manager dealt with complaints effectively. We saw that not all complaints were recorded and most were dealt with informally. People’s relatives however told us when they had complained they had been happy with the response from the registered manager.

The registered manager arranged for different audits to be done at the home. Some of these audits had been effective in ensuring the service was of a high quality, for example the monthly health and safety report. Other audits had not highlighted areas for improvement at the home.

We spoke with three people who lived at the home and four relatives. Comments from people who lived there included "Yes it's fine here, I am supported" and "I know the staff, they are very kind". One relative said "I come in at different times of every day. The patience of the staff is tremendous. They are so lovely and they distract people from challenging situations". Another told us "I've had a couple of issues, I've raised them with staff and management and it's all been sorted out" and "I come here nearly every day. I would know if things were not good".

We looked at six people's care records. Each person's needs had been assessed and care plans covered physical, emotional and behavioural needs. Each plan had an associated risk assessment and there were clear instructions to staff on how each risk should be managed.

Staff were able to describe the different forms of abuse and were able to tell us how they would report an issue of concern. We looked at staff training records and saw that all staff had been trained in the safeguarding of vulnerable adults.

The provider may find it useful to note that we noticed a strong unpleasant odour throughout the property. This was particularly evident in the lounges where people who used the service and their relatives, appeared to spend most of their time. This meant people spent most of their time in an environment which smelled unpleasant. Relatives said the smell was evident to them and they had highlighted it to the manager. The manager said she had requested new furnishings for the home but these had not yet been authorised.

We reviewed staff files and saw that necessary pre-employment checks had been carried out. The provider may find it useful to note that in two cases risk assessments had not been completed for members prior to their employment. This had been highlighted by the local commissioners and we saw that these had been put in place. Staff told us they felt well supported to care for the people they looked after.

We saw that people were treated with respect and dignity. Carers explained what they were doing before they did it and people were given choice. Records clearly indicated consent had been requested and agreed.

Dinner time was a social event where people chatted, carers interacted and help was provided if required. Hot food was offered at breakfast lunch and evening meal. People's dietary likes, dislikes and needs were recorded and kitchen staff were informed of any special requirements. Nutritious milkshakes were prepared and offered to everyone.

There were sufficient staff available and it was evident at our visit that the home managed unplanned incidences of staff absence. Staff told us 'There are times when we could do with more hands, but on the whole we manage very well' and 'We work as a team, so it all runs smoothly'.

We followed up a compliance action in relation to records and looked at seven care records. We found that all issues highlighted at the previous inspection had been addressed.

We spoke with three people who used the service. All said they felt cared for and respected by the staff team. We spoke with four family members. All said they were happy with the care and support offered to their relatives and felt involved in their care.

Overall we observed staff engaging with people in a sensitive and caring manner. We did however observe two incidents of poor practice with regard to not offering appropriate support to people with dementia with their nutritional needs and not involving people in decision making.

The training record for the staff team was viewed and showed all staff had completed training around safeguarding vulnerable adults from abuse in the last 12 months. Discussions with members of staff confirmed this information

People who used the service, their representatives and staff were asked for their views about how the service operated. Records showed action plans were in place to resolve any issues identified.

Care records held limited information about how people with dementia communicated their needs including if they were experiencing pain, were hungry or anxious. They also held limited information on how the staff were to support people who were presenting with aggressive behaviour. The manager told us care plans and risk assessments were being reviewed.