Birchmere House

We found the following examples of good practice.

• All staff complied with personal protective equipment (PPE) guidance with no identified issues related to its usage.

• Automatic doors had been installed in high flow areas to remove the need to touch door areas in order to pass through.

• The 3 separate floors allow the service to reduce unnecessary movement onto each floor and can be used as an effective control measure if an outbreak occurred.

Birchmere House provides residential and nursing care to older people. The home has three floors accommodating up to 76 people in one adapted building. On the day of our visit 53 people lived at the home and two of these people were in hospital. The home is located in Solihull, West Midlands.

Recently, the service provision changed. The provider for the home is now two separate companies with joint responsibility for the home. The name of the service also changed from ‘Birchmere’, to 'Birchmere House'. The changes in registration delayed the publication of this report.

Our last inspection took place on 29 September and 17 October 2016. This inspection was a focussed responsive inspection where we looked at the key questions of ‘safe’ and ‘well-led’.This was in response to information we had received in relation to people's safety and how risks were managed, particularly in the reminiscence area for people living with dementia. However, since that inspection the providers have closed the reminiscence area of the home and the maximum occupancy at the home has reduced from 131 to 76. Prior to this, our last comprehensive inspection where we looked at all five key questions of safe, effective, caring, responsive and well-led, was March 2016.

At the focussed inspection we found there was one continued breach of regulation 17 (Good governance) associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014. The home was rated as ‘Requires Improvement’. This was because further improvements were required to establish systems and processes and to complete accurate and up to date records of each person’s care and treatment.

The provider sent us an action plan which stated all the required improvements would be completed by 20 May 2017. During this inspection we checked whether the improvements had been made and we found sufficient action had been taken in response to the breach in regulation.

There was a registered manager at the home. They had started work at the home in June 2017 and registered with us in December 2017. 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.

People felt safe living at Birchmere House and there were enough staff to support their care needs in a timely way. Procedures were in place to protect people from harm. The staff and the registered manager understood their responsibilities to keep people safe. Staff had received training in ‘safeguarding adults’ to protect people from harm and described to us the signs which might indicate someone was at risk.

Processes were in place to keep people safe in the event of an emergency. People had personal fire evacuation plans and staff understood the actions they needed to take in the event of an emergency. Accidents and incidents that happened in the home were monitored and action was taken to reduce the risk of reoccurrence. Checks took place to ensure the environment and equipment was safe to use.

The provider’s recruitment procedures minimised risks to people’s safety. Recruiting new staff had been one of the provider’s priorities over the previous six months to ensure people received consistent care from familiar staff. New staff received effective support and training when they started working at the home. Staff had completed the training they needed to be effective in their roles.

Risk assessments identified potential risks to people's health and wellbeing. Staff had a good knowledge of the risks associated with people’s care and how these were to be managed.

People received their medicines as prescribed. People confirmed they received effective care, support and treatment from health professionals to maintain their health.

People’s needs were met by the design of the building. The home was warm, clean and well maintained. Staff understood their responsibilities in relation to infection control which protected people from the risks of infection.

The providers were working within the requirements of the Mental Capacity Act (2005). The registered manager and staff demonstrated they understood the principles of the Act. Staff had received MCA training and sought people’s consent before providing assistance.

People spoke positively about the food provided at the home and had opportunities to be involved in creating menus. Staff, including the chef, demonstrated good knowledge of people’s individual dietary needs.

The atmosphere at Birchmere House was warm and friendly. People told us the staff were caring and showed them kindness. People were supported to maintain relationships with those closest to them.

Staff and the registered manager understood the importance of promoting equality and human rights as part of a caring approach. People received care that was responsive to their needs and personalised to their preferences. Each person had their needs assessed before they moved into the home and people planned and reviewed their care in partnership with the staff.

People’s care plans included their life history and information about their preferred routines, lifestyle choices and achievements. This supported staff to provide person centred care. Care plans detailed people’s future wishes for end of life care. When needed staff worked in partnership with other healthcare professionals to ensure people had a comfortable and pain free death.

People maintained positive links with their community. A variety of activities took place at the home and people had opportunities to take part in activities which supported them to pursue their hobbies and interests.

People knew how to make a complaint and felt comfortable doing so. The registered manager told us they used complaints as an opportunity to drive continuous improvement in the home.

People spoke positively about the home and the registered manager. Staff told us Birchmere House was a nice place to work. The registered manager and the provider were committed to recognising the contribution individual staff members made to benefit people. Staff had regular opportunities to attended meetings with the management team and they received regular supervision and an annual appraisal of their work performance.

The registered manager promoted an open and transparent culture. Staff told us communication in the home was good and recent positive changes had been made to drive improvements. Staff attended daily meetings to share information about people. This meant staff had the information they needed to provide the care and support people required.

The registered manager felt supported by the provider. They used different methods to ensure they kept their knowledge of legislation and best practice up to date. The provider supported the registered manager to further develop their skills to support the values of the organisation.

Effective systems were in place to monitor and review the quality of the home. People and their families had opportunities to put forward their ideas and suggestions to improve the service they received. The feedback received was analysed and used to drive forward improvements.

At our last comprehensive inspection in March 2016, we found there was a breach in the legal requirements and Regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to good governance. Systems and processes to monitor and improve the quality and safety of services provided, and to manage risks related to the health, safety and welfare of people, were not established. This included records not always being sufficiently detailed and accurate to support safe and appropriate care.

We asked the provider to take action to improve the areas we had identified as being of concern. The provider sent us an action plan which detailed the actions they were taking to improve the service.

Following this inspection we were made aware of further concerns in relation to people’s safety and how risks were managed, particularly in the Reminiscence area. As a result we undertook a focused inspection to look into how the risks associated with people’s care was managed, whether people were safe and whether the home was well – led.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Sunrise Operations Knowle Limited on our website at www.cqc.org.uk

At this inspection we found that whilst some actions had been taken to drive improvement in relation to the processes to support people’s safety and manage risks, further improvements were still required in relation to the governance of the service. This meant there was a continued breach of this regulation.

A requirement of the service’s registration is that they have 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 a 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 a registered manager in post who had been registered since July 2016.

There were not always enough staff available to provide the support people required in order to meet their needs and preferences, particularly over the lunchtime period. New staff had been recruited resulting in a reduction of temporary staff being used, but at times people were still not supported effectively.

Risk assessments were completed to reflect the risks to people’s health and wellbeing; however we found some had not been reviewed regularly and were inaccurate, so we could not be sure people would be supported correctly. However, staff spoken with knew the risks to people when providing care and other care records were now being completed accurately and in a timely way following the introduction of a new system.

Continued changes within the management team had affected staff confidence and some staff told us they found the changes unsettling. Some staff told us they felt supported through meetings and supervision, however other staff did not.

Overall people, relatives and staff felt there had been some improvements at the home. More staff had been employed and less agency staff were used. There were opportunities for people and staff to raise concerns with the management team.

People and relatives told us people felt safe at the service. Medicines were administered as prescribed, and stored and disposed of safely.

People had opportunities to feedback about the service they received through surveys and meetings.

Staff were trained in safeguarding adults and understood how to protect people from abuse. The provider ensured checks were carried out prior to new staff starting work to minimise the risk of recruiting unsuitable staff.

The management team had identified care records required further improvement and had plans in place to address this area. Audits had been undertaken to check the quality and safety of the service and to identify areas which required improvement.

We found a continued breach 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.

The service is registered to provide care for up to 131 people and offers accommodation for people who require nursing or personal care. At the time of our inspection there were 114 people living at the service. The home is divided into two units, the Assisted Living area and the Reminiscence area, for people living with dementia.

A requirement of the service’s registration is that they have 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A registered manager had not been in post since October 2015.

A new manager had been in post since January 2016, and was in the process of applying for registration. We have referred to them as the ‘manager’ in the report. A temporary general manager was also employed managing the Reminiscence area of the home, and we have referred to them as the ‘general manager’ in the report.

We completed an unannounced focused inspection on 16 November 2015. This inspection was in response to concerns we received about how people’s care was managed. This included people who were at risk of falling and the management of people’s medicines. The inspection team visited the service and looked at two of the five questions we ask about services: is the service safe and is the service well-led. At this visit we identified a breach of regulation in relation to how the provider monitored and assessed the quality and safety of the service provided. Also a breach of regulation in relation to safe care and treatment of people in relation to the management of medicines, and in relation to staffing levels, and how staff were supported.

We visited this service again on 7 March 2016 following further concerns raised in relation to the management of medicines and the safety of the care provided. At this visit we found that some improvements had been made in the management of the service, however we continued to have concerns in relation to how people’s care was provided. At times, the quality and safety of care people received remained unsatisfactory and there were not always enough staff available to support people at the times required. We sent the provider a letter outlining the areas for urgent improvements. Following this, the provider sent us an action plan detailing how they would improve.

We returned to the service on 24 March 2016 to complete our inspection and also review the management of medicines. At this visit we reviewed the action plan that the provider had sent us in March 2016. We found that improvements had been made and actions had been taken in relation to most of the areas of concern. Where action had not yet been taken, the management team were able to show us plans to address the other areas of concern. Although some further improvements were still required, the provider was no longer in breach of the regulations in safe care and treatment of people, in relation to the management of medicines, and in relation to staffing levels. However, they were still in breach of the regulation in relation to how the provider monitored and assessed the quality and safety of the service provided, as these systems were not yet established.

At our visit on 7 March we had found people’s health and social care needs were not always reviewed regularly. Care records were not always completed by staff correctly. Staff told us this was because they did not always have time to do this. Risk assessments were completed, however plans did not consistently minimise the risks associated with people’s care.

Although more staff were being recruited, there was not always enough staff available to support people at the times they preferred. Staff were not always able to respond to people’s needs effectively and equipment was not always available when staff required this.

However, at our second visit on 24 March, the care records we checked had been completed correctly. Risk assessments had been reviewed by staff and updated to accurately reflect the risks to people and how they should be minimised. The management team had taken further steps to employ more staff and staff told us they were now starting to feel more positive about staffing levels, as the new staff started. New equipment had been ordered to support staff in supporting people with their care.

People’s nutritional needs were met and special dietary needs were catered for. However, at times staff were unaware of people’s dietary needs, which had the potential to place them at risk. Following this concern being raised by us, the management team arranged further training for staff to support them in this area.

Staff had training in order to meet people’s care and support needs. However, staff told us they felt they did not always benefit from computer training and that they would like further training in some areas, which the management team were now arranging.

People took part in some organised activities and trips, and told us there was plenty for them to do. It had previously been identified that activities could be further improved for people living with dementia and steps were being taken to address this.

People were treated with dignity and respect by staff when supporting them. Relatives were encouraged to be involved in supporting their family members.

People told us they liked living at the service and that most staff were kind and caring. People were cared for as individuals with their preferences and choices supported most of the time. However, people told us they did not always receive support from staff who knew them well.

People and staff were positive about the new management team and felt there had started to be some improvements at the service. The management team were beginning to make positive changes to the service people received.

Staff told us they felt supported by the new management team to carry out their roles effectively. Staff told us morale was beginning to improve at the service.

People told us they felt safe living at the service. Staff knew how to safeguard people and what to do if they suspected abuse. Checks were completed prior to staff starting work at the service to make sure they were of good character and to ensure their suitability for employment.

People were protected from harm as medicines were stored securely and systems ensured people received their medicines as prescribed.

Staff referred to other health professionals when needed, so people were supported to maintain their health and wellbeing.

Staff understood the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLs). Staff ensured they gained consent from people before supporting them with care.

The manager was responsive to people’s feedback in developing the service, and making continued improvements, such as recruiting more staff, supporting staff further, ensuring people received care that met their needs and that this was accurately documented. Systems and checks made sure the environment was safe. People knew how to complain if they wished to, and complaints were being recorded and responded to by the management team in a timely way.

The provider had displayed their last inspection ratings, as is the legal requirement to do this.

We found a breach 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.

When we inspected the home there were 112 people living there. The home was laid out over three floors and occupied two separate units. One unit was called 'Assisted Living' for people who had some levels of independence and the other unit was called 'Reminiscence' for people who had varying levels of dementia related illness. Both homes provided nursing care to people.

At our previous inspection in February 2014 the provider was not meeting the regulations in relation to care and welfare and staffing. Following the inspection the provider sent us an action plan to tell us the improvements they were going to make. During this inspection we looked to see if these improvements had been made. Prior to our follow up inspection we received concerns from people and relatives of people who used the service. These concerns were around the levels of care and support people received and also concerns with medicines.

We carried out observations of care throughout the home during our inspection. The evidence we collected helped us to answer five key questions; is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, staff and visiting relatives told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

At this inspection we found improvements had been made since our last inspection however further improvements were still required. We saw care records did not contain enough information about people's individual needs. For example, we found insufficient information and guidance was available to staff for people who displayed challenging behaviours.

We observed staffing levels during our visit. There were times when there was no visible staffing presence to assist or support people if they needed help. Some of the people we spoke with also expressed their concern over staffing levels, particularly in 'Reminiscence' unit.

The home had policies in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). We saw no recent DoLS applications had been submitted. The deputy manager was aware of the latest guidance and information on DoLS and was planning a review of people's needs in light of this guidance.

People were not protected against the risks associated with medicines because the provider had not made appropriate arrangements to manage medicines safely.

Is the service effective?

We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people's care and support needs remained appropriate. We were aware that the provider had started to review care plans, however further improvement were required. We found some care plans had not been reviewed for some time and people's care needs had changed, but records did not reflect this. We have asked the provider to tell us how they will make improvements.

We found it was not always clear from speaking with staff that they had a good understanding of people's care needs. We saw some care records did not contain people's life histories or personal background information. This made it difficult for some staff to know people well enough to support them appropriately. We have asked the provider to tell us how they will make improvements.

Is the service caring?

We saw staff were attentive to people's needs throughout our inspection; however we also saw examples were people did not receive the individual support they needed. For example, one person required support to eat and when they refused, the staff member did not provide any encouragement or further assistance.

Is the service responsive?

People were able to make choices about their day to day lives and people in 'Assisted Living' had access to all parts of the home. We saw couples were able to share a room which meant people had a choice in how they wanted to continue to live their own lives.

We saw people were supported to remain as independent as possible. Staff we spoke with told us how they supported people to do this.

Is the service well led?

People were able to access help and support from other health and social care professionals when necessary.

We found on some floors nursing staff and care staff did not always have a clear understanding of who was leading the shift.

Three inspectors visited the service. Two inspectors visited the reminiscence unit, and one inspector visited the second floor of the assisted living service.

Sunrise Knowle had a newly appointed general manager and deputy manager.

We saw a twelve point action plan was in place highlighting areas for improvement. For example, end of life care, medicines management, and nutrition.

We observed staff interacting with people with kindness, one person told us, 'Staff are excellent, I have everything I need '. We reviewed the care of six people with varying levels of need. We found care plans did not always reflect people's needs.

We saw people were offered a range of meal choices, and their nutritional needs were met.

The service acted appropriately to reduce the risk of harm to most people, however we saw people were not always protected against the risk of pressure ulcer development.

We saw staff had attended mandatory training, however there was poor uptake on specialist training and staffing levels did not ensure care was delivered in a timely way.

Improvements were being made at Sunrise Knowle but significant further work was still needed.

We visited the home in August 2013 and spoke at length with the Deputy Manager about the changes that had taken place. We also looked at a number of records including care plans, risk assessments and staff training documents.

We found care documentation files were much more organised. Out of date paperwork had been archived from the files. Records of staff training reflected the actual training staff had undertaken or were due to complete.

Regular staff meetings were being held to discuss aspects of care practice including record keeping and reporting. The minutes of which were documented and referred to as necessary.

The providers action plan had been fully implemented, and we found the service to be compliant.

The atmosphere in the home was welcoming. Staff were professional and friendly, people living there were settled and engaged in conversations and activities, and visitors to the home were made very welcome.

We spoke with eleven people living at the home, fourteen members of staff and two relatives who were visiting at the time of our inspection.

Staff had received training in dementia care and this was evident from the interaction we observed. Staff now took the time to sit with individuals and offer choice and options, not just decide what was best for them.

Recruitment was much improved. A number of staff had been appointed to fill the outstanding vacancies. The manager was confident that within six weeks the home would be fully staffed by permanent staff and there would be no need to use agency staff. People living at the home told us there were less agency staff being used and they liked having staff who knew them well.

The provider had recognised this and had brought in an experienced management team, six weeks prior to our visit. During the short time the management team had been in place they had made a great number of changes throughout the home. Detailed action plans were in place for all areas of the service and we could see evidence of improvement during our visit.

The home remains non-compliant. Although plans were in place to improve the service there was still a lot of work needed before the home could be classed as compliant.

Sunrise Knowle consists of two separate buildings on the same site. One for general residential and nursing care, and the other for dementia residential and nursing care. During our visit we spent time in both buildings and spoke to staff and people living at the home.

People living in the general carehome told us staff were hard working, kind and very helpful. We were unable to get any comments from people living in the dementia carehome due to the nature of their illness.

Staff told us morale had been low amongst the staff team. They felt that with the new management team in place things were slowly improving. They felt able to talk to the managers and express their views.