All inspections: Birch Abbey - Care Quality Commission

The inspection took place on 10 & 11 April 2018 and was unannounced. The last inspection of the service was 6 & 7 January and 14 April 2016 and the rating for the service following this inspection was Good.

Birch Abbey 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.

Birch Abbey is a care home providing personal and nursing care. It can accommodate up to 60 older people. At the time of the inspection 58 people were living at the home. The service specialises in caring for people with dementia.

A registered manager was 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.’

At this inspection we found a breach of regulation. People’s plan of care lacked information around care and support. This meant there was a risk staff did not have the information they needed to meet people’s care and support needs effectively and in accordance with individual need and preference. Governance arrangements to asses and monitor standards in the care home were not always effective to ensure the service was managed safely. Record management needed to improve as some information was difficult to locate.

The environment was maintained and subject to service contracts and safety checks of obvious hazards. Not all of these were current though the registered manager took immediate action to rectify this.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person's mental capacity was made. Sixteen people were being supported on a Deprivation of Liberty (DoLS) authorisation. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.

Staff understood the concept of safeguarding knew how to report any concerns. Records indicated that safeguarding referrals to the local authority had been made appropriately.

Medicines were administered safely to people. Staff received medicine training and had been deemed competent for their administration.

Risks to people safety and wellbeing were recorded to enable staff to support people safely whilst promoting their independence. Staff recorded actions to maintain people’ safety.

Accidents and incidents were recorded and analysed to look for patterns and trends.

People at the home were supported by the staff and external health and social care professionals to maintain their health and wellbeing.

Staff were deployed in sufficient numbers to keep people safe and meet their needs.

The registered manager obtained required checks before an employee's commencement in post to ensure staff were suitable to work with vulnerable adults.

Staff received training and support to care for people in accordance with their individual needs. This included more specialised training to support people with dementia.

Our observations showed good interaction by the staff with people they supported. Staff were attentive, kind and respectful in their approach.

Staff were aware of their responsibility to treat people equally and respect their diversity and human rights.

Relatives told us the staff respected their family member’s rights to privacy and dignity and staff looked after people well.

Our discussions with staff confirmed they had a good knowledge and understanding of the people they cared for. We saw care being provided in accordance with individual need.

People’s dietary needs were managed with reference to individual preferences and choice. Pictorial menus were available for people to help choose their meal.

A new social activities programme was in place to help people engage with hobbies they enjoyed and to provide some structure and normality for their day.

Staff were positive about the management and leadership of the home. Staff told us they were able to share their views openly.

A complaints’ procedure was in place and relatives we spoke with were aware of how to raise a concern.

Birch Abbey had a clean environment and we observed good adherence to the control of infection.

Relatives and visitors were welcomed at the home and kept up to date about their family member.

There was a system in place to get feedback from people and/or their relatives so that the service could be developed with respect to their needs and wishes. These included meetings and satisfaction surveys.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory notifications. The ratings from the previous inspection were on display in accordance with requirements.

You can see what action we took at the back of this report.

This unannounced inspection took place on 6 and 7 January 2016 and 14 April 2016.

This inspection was also to follow up on the concerns which were identified in a previous inspection on 16 & 17 June 2015. The home was rated as ‘requires improvement’ overall. The provider sent us a plan following this inspection of actions they were going to take to ensure the breaches were met. We found during this inspection that the provider had met these breaches.

Birch Abbey is a care home providing personal and nursing care. It can accommodate up to 60 older people. The home specialises in caring for people with dementia. The home is owned by Melton Health Care Ltd. The accommodation is purpose built and planned over four floors. It is located in a residential area close to Southport town centre.

Processes relating to the safe administration of medications were in place within the home. We observed people being given their medications appropriately.

People and relatives we spoke with told us they felt safe living at the home.

Risk assessments were in place and personalised. These were reviewed on a regular basis for any change.

The staff we spoke with were aware of what constituted abuse and how to report an alleged incident.

Recruitment procedures were robust to ensure staff were suitable to work with vulnerable people. Systems were in place to maintain the safety of the home. This included health and safety checks of the equipment and building

Most staff had regular supervision and appraisal. We saw a plan in place to ensure this took place with the remaining staff in the next few weeks.

People had a plan of care in place which was personalised and contained information such as their likes, dislikes and backgrounds. As well as other information relevant to their needs ensuring they got the care which was right for them.

The registered manager and the staff had knowledge of the Mental Capacity Act (2005) and their roles and responsibilities linked to this.

The home had aids and equipment to meet people’s needs and staff would encourage people to do things for themselves when it was appropriate to promote their independence.

We found the home to be clean, spacious and well decorated. The provider was in the process of making even more improvement to the home’s already ‘dementia friendly environment’.

Food was fresh and home cooked. Everyone we spoke with told us that they enjoyed the food and got enough to eat and drink.

Staff referred to outside professionals promptly for advice and support.

A process was in place for managing complaints and the home’s complaints procedure was available so people had access to this information.

People and relatives were complimentary about the manager even though they had not been in post for very long.

Staff were aware of the home’s whistleblowing policy and told us they would not hesitate to report any concerns or bad practice.

Systems were in place to monitor the standard of the service and drive forward improvements. This included a number of audits for different areas of practice, and clear and transparent action plans when areas of improvement were identified by the audit process.

The inspection took place on 16 and 17 June 2015 and was unannounced.

Birch Abbey is a care home providing personal and nursing care. It can accommodate up to 60 older people. The home specialises in caring for people with dementia. The accommodation is purpose built and planned over four floors. A passenger lift provides to access all areas of the home. Single bedrooms with ensuite facilities are provided over three floors. There is a large secure garden area at the side and rear of the home and parking facilities at the front of the building. It is located in a residential area close to Southport town centre. There were 48 people living in the home at the time of our inspection. The provider also provides support in people’s own homes. One person currently receives this support.

A registered manager was 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.’

Staff understood how to recognise abuse and how to report concerns or allegations.

There were enough staff on duty at all times to ensure people were supported safely.

We saw the necessary recruitment checks had been undertaken so that staff employed were suitable to work with vulnerable people. However we found that some staff had started work at Birch Abbey prior to a DBS check being completed and returned and references being received from their previous employer. DBS checks consist of a check on people’s criminal record and a check to see if they have been placed on a list for people who are barred from working with vulnerable adults.

Staff said they were well supported through induction, supervision, appraisal and the home’s training programme.

We found medicines were not always administered safely to people. Some medication administration records were incorrectly completed and showed inaccurate medicines.

Staff sought people’s consent before providing support or care. The home adhered to the principles of the Mental Capacity Act (2005). Applications to deprive people of their liberty under the Mental Capacity Act (2005) had been submitted to the Local Authority. Staff had a good understanding of the Mental Capacity Act (2005) about how the act applied in a care home setting.

People told us they received enough to eat and drink, and they chose their meals each day. They were encouraged to eat foods which met their dietary requirements.

The building was clean, well-lit and clutter free. Measures were in place to monitor the safety of the environment and equipment. We found the home did not always promote a positive dementia - friendly environment.

People’s physical and mental health needs were monitored and recorded. Staff recognised when additional support was required and people were supported to access a range of health care services.

Staff we spoke with showed they had a very good understanding of the people they were supporting and were able to meet their needs. We saw that they interacted well with people in order to ensure people received the support and care they required. We saw that staff demonstrated kind and compassionate support.

We saw that people’s care plans and risk assessments were regularly reviewed. People had their needs assessed and staff understood what people’s care needs were. Referrals to other services such as the dietician or tissue viability nurses and GP visits were made in order to ensure people received the most appropriate care.

Different activities that were provided for people who lived in the home. There was little in the way of stimulation for people who were on the first and second floors.

The home had a complaints policy and processes were in place to record complaints received. This ensured issues were addressed within the timescales given in the policy.

We found person-centred culture within the home. This was evidenced throughout all of the interviews we conducted and the observations of care.

There were systems in place to get feedback from people so that the service could be developed with respect to their needs.

The service had a quality assurance system in place with various checks completed to demonstrate good practice within the home. Checks for medication administration were not robust enough to correct errors when they were identified.

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

This was an unannounced inspection of Birch Abbey. The inspection set out to answer our five questions:

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who lived at the home, their relatives, staff providing support and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

The people we spoke with told us staff were caring and treated them with kindness and respect.

The home was clean, hygienic and odour free. Measures were in place to ensure the environment was safe and suitable for the people who were living there.

Although a busy home, both people who were living there and staff told us there was enough staff on duty to ensure people's safety. The manager set the staff rotas; they took people's care needs into account when making decisions about the numbers of staff required. This helped to ensure that people's needs were always met. People we spoke with confirmed this.

The home protected the rights and welfare of the people in accordance with the Mental Capacity Act (2005). At the time of the inspection there were Deprivation of Liberty Safeguards (DoLS) in place to keep people safe. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom.

The manager had a process in place to review accidents each month so that a reoccurrence could be minimised in the future.

Is the service effective?

It was not always possible to get the views of people who lived at the home due to their frailty and level of confusion. People we spoke with did, however, tell us they were happy with the support they received from the staff.

People's health and care needs were assessed with them and/or with a family member. People and family members told us staff communicated well about care needs and any changes were discussed with them. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People's care plans reflected their current needs.

Where specialist support was needed, for example, with a person's nutrition, mobility and use of equipment, this had been sought in a timely manner to help improve people's health, well-being and independence.

Is the service caring?

The people we spoke with told us the staff were kind and helpful. People's comments included, 'The staff look after my relative well', 'My relative looks well cared for. The family are very happy with the service' and "The staff are excellent. They can't do enough for them.'

Throughout the day we observed staff prompting and encouraging people in a kind and respectful way. Care and support was given when people requested and needed it. The staff ensured people's comfort and dignity at all times.

Staff had a good knowledge about people's care needs and how they wished to be treated. This included people's dietary preferences. Meals served were according to people's individual wishes and requirement.

People who lived at the home and their relatives had the opportunity to participate in regular satisfaction surveys.

Is the service responsive?

People's needs had been assessed before they moved into the home. Records confirmed people's preferences, interests, and needs had been recorded and care and support had been provided in accordance with people's wishes.

From our discussions with staff and looking at a number of care records, we could see that people's plan of care was revised to meet any change in need. For example, deterioration in a person's medical condition. Care documents showed medical intervention had been sought at the appropriate time.

People knew how to make a complaint or raise a concern if they were dissatisfied with something. The complaints procedure was usually displayed in the reception area. The policy had recently been updated and a copy had not yet been put back for people to see.

Staff ensured people had a choice of menu and when they requested something different this was provided.

Is the service well-led?

People had to opportunity to provide feedback about the home by completing an annual questionnaire.

The home had systems in place to regularly monitor the quality and safety of the service provided. Records we looked at demonstrated that action plans were developed to address identified shortfalls in a timely way.

Staff we spoke with said they received good quality training. We saw that staff received supervision every four months and an annual appraisal each year.

The service worked in partnership with key organisations, including the local authority and safeguarding teams to support the care provision and service development. This was evidenced through looking at a number of records and talking with the manager and staff.

The home had a Registered Manager in place at the time of our inspection.

We visited Birch Abbey to review our findings of non-compliance in two outcomes at our inspection in September 2013. At this unannounced inspection we spoke with the manager about the changes that had been made since the last inspection in July 2013.

We looked at staff rotas and training documents. We made a thorough inspection of the home and looked at the improvements that had been made. We observed how people were cared for. We spoke with five staff about the changes that had been made since our inspection in July 2013.

We found appropriate arrangements had been made for the handling of people's medicines but noted that some of the medicines record keeping could be improved to better support and evidence the safe administration of medicines.

Some people living at Birch Abbey were less able to express their views about medicines handling at the home due to a variety of complex needs. We observed part of the morning medicines round and saw that patient support was offered where people needed help with taking their medicines. Homely remedies were kept to enable care workers to respond quickly to minor ailments such as, a cold.

We saw some good standards of care in the home and people were supported to maintain their independence as much as possible. One person commented, 'I'm very independent and do things for myself. Staff bring me a newspaper which I like to read in bed in the mornings. I like my privacy and independence and they respect this when caring for me.' Another person had been assessed carefully and supported to have trips out into the community on a daily basis. We found people were supported with their general health and staff ensured that appropriate referrals were made when people needed medical assessment.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We found, from observations made and comments received on the inspection, that the quality of care was not as consistent with people with more dependent care needs. This related to supporting some people with aspects of care at peak times such as meal times and in the morning.

There were not enough qualified, skilled and experienced staff to meet people's needs. We saw that people with higher dependency care needs did not have care delivered at the right time. From our observations and comments we received from staff and people using the service we found staff to be 'pressured' in their work and this meant that people's individual care was not maintained at times.

The provider did have systems in place to identify the support required by staff. Some staff, however, did not feel supported at times, and formal systems such as training and supervision to support staff still needed developing further and updating.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We spoke with people living at the home, who were able to express an opinion and their relatives about how medicines were managed. Everyone we spoke with was happy with the arrangements in place when staff administered their medicines.

There were enough qualified, skilled and experienced staff to meet people's needs. One relative commented, ' Staff are lovely and there seems to be enough around.' Another said, 'The staff are very responsive and approachable. I spoke with them about my relatives routine and staff make sure [the person] is supported which helps.'

There was an effective complaints system available. Comments and complaints people made were responded to appropriately. We saw the record of complaints received in the home and reviewed these with the manager. The manager was able to discuss these in detail and demonstrate how they had been addressed.

We spoke with a number of people who lived in the home, as well as visitors. People spoke positively about how staff included them in the care and confirmed that staff asked for their consent to care and treatment, as required. A relative we spoke with said that staff took time to explain any changes to care and kept them informed, so that decisions could be made in the person's best interests.

We spoke with one person who was able to give an account of their care in the home. They felt that the staff approach was good. The person was able to discuss their condition and said that staff spent time and helped support them to come to terms with life at Birch Abbey. They commented, 'Staff explain things to me.'

A relative said that, 'Staff at Birch Abbey are marvellous.' Their relative had been particularly challenging and staff had always 'Done their best' to support the person and had forged strong bonds with them as relatives' and 'They have tried to include us in the care'.

We spoke with one person who felt that some aspects of care were not consistent. This related to a period of 'respite' care where the person had been admitted for a short time. When they returned home the relative said that the personal care had 'not been up to standard'.

Another relative said, 'Overall the care is good and the staff are excellent. I have some concerns that the day space is not enough for people to sit comfortably and this can be particularly bad when visiting.'

We spoke with some of the people living in the home although responses varied depending on how well people were able to communicate and express a view. One person commented that they felt well cared for. They felt staff were 'very good and they spend time to talk to me about my condition.'.

People wishing to self-administer medicines were, where possible, supported to do so. One person confirmed that they were happy with the arrangements in place and had everything they needed.

On our last visit to the home in October 2011 we had some concerns around how the service deals with issues around consent and decision making capacity. This included how people's mental capacity was assessed. This is crucial in determining people's ability to make key decisions for themselves or whether care is organised in their best interests.

Generally people spoke positively about how staff included them in the care and confirmed that staff asked for their consent to care and treatment as required.

We spoke with one person, however, who said that prior to admission they had managed their own medications but this had been 'Taken off me' following admission. Although the person was not unduly concerned there had been no choice offered to them.

We had other concerns that records supporting people's rights to make informed decisions were absent and there was a lack of awareness by the manager and staff. Lack of clear awareness and records here was a concern. This was highlighted on the previous inspection and the same lack of knowledge persisted on our follow up visit.

People varied in their comments about the home and the quality of the care. Most felt that the overall care was good. One person commented 'Overall the staff manage very well. It's a very difficult job and staff are always patient and kind.' We spoke with one person who felt that some aspects of care were not consistent. Their relative had not received good standards of personal care at times and other aspects of care such as medication management had been inconsistent. Another visitor felt that there were times when staff delayed getting the doctor to visit and had to be reminded.

We visited the home to follow up on concerns and compliance actions [requirements] we have made previously.

On this visit people spoke positively about how staff included them in their care and confirmed that staff asked for their consent to care and treatment as required. For example staff always ask people regarding daily personal care. Relatives said that staff took time to explain any changes to care and kept them informed.

We took time to assess how the service deals with issues around consent and decision making generally. This includes how people's mental capacity is assessed. This is important in terms of their ability to make key decisions for themselves or whether care is organised in their best interests. There is currently no assessment carried out by the home regarding people's capacity to make key decisions for themselves. This was discussed with the manager as an area that needs developing and clearer understanding evidenced.

We saw staff attending to people who needed assistance with mobilising and assisting people to eat. The dependency of people living in the home can vary considerably but those people able to give an opinion as well as visiting relatives said the overall standard of care was good and that staff were consistent in their approach. People looked clean and said that they had chosen how they were dressed. This showed staff paid good attention to standards around personal hygiene.

We spoke with one person who said, ''The staff look after me very well. There's plenty of staff about, I only have to call them''. There was evidence of good orientation aids and good practise around dementia care such as 'memory boxes' , which were positioned outside bedrooms. This allows for easier identification and orientation regarding bedrooms for people as well as providing a focus for discussion and interest.

Some people living at Birch Abbey were unable to directly express their views about their medication due to a variety of complex needs but we observed part of the morning medicines round and saw that care workers spoke to people in a polite and kind manner. We saw that records were completed at the time medicines were given to help ensure their accuracy. There have been some improvements in the way medicines are managed but overall we still have concerns and more improvement is needed.

People spoken with said that meals provided were good and there was a choice available. We saw plenty of staff involved in serving and supporting people with their diet. The pace of the meal observed was appropriate and sociable.

Those people spoken with were very relaxed around staff and said that they were listened to so that any concerns could be addressed. When asked people said they felt 'safe' and they were confident that any concerns would be listened to and addressed.

We received positive comments from people about the staff which helped evidence their competency and approach to care. Comments included:

''Staff are very good. They always make sure my mum wears her hearing aid''

''Staff are fantastic ' they create a good feeling of freedom for people''.

''Staff always let me now what's happening and ask me if I need to see a doctor. I see how they look after other people ' very good care''.

People reported that staff numbers were consistent and staff said that there is a good moral so that staff support each other and work well together. They reported that staffing had improved overall.

People told us that they are consulted about their care and about aspects of the running of the home. Interviews confirmed that the general running of the home is consistent.

We had some concerns expressed prior our visit by various health and social care professionals as well as relatives of people using the service. These related to how people have been managed generally with respect to ensuring safety and wellbeing. For example there have been a number of safeguarding incidents involving people with bruising. Some concerns were around how people are being observed now that the home is much larger in size.

We visited the home and spoke with people and their relatives. They felt standards of care were good and they felt they were kept informed about the care.

We spoke to some health care professionals who have had recent input in terms of supporting people in the home. Generally they felt that people placed at Birch Abbey were supported and staff were able to carry out care as planned.

People spoken with were very relaxed around staff and said that they were listened to so that any concerns could be addressed. We observed staff interacting with people living in the home in a positive and supportive manner. Relatives spoken with were also positive. All felt that staff approached care well. They also felt that they could approach the manager and staff with any concerns and felt they would be addressed.

We observed part of the morning medicines round and saw that care workers spoke to people in a polite and kind manner. However, care workers did not always follow current good practice guidance when administering medicines. We have a concern about this.

Prior to our visit to the home we received information from Sefton Social Services that following investigations they had conducted it was felt that there may not be enough flexibility in the carer to resident ratio to enable safe care at times such as escorting people to hospital. This is important as people with dementia cannot often speak for themselves to relay important information as well as being anxious and disorientated with such an experience. On the site visit we spoke to a number of relatives of people living at Birch Abbey and they told us that staffing was not an issue and that there seemed to be plenty of staff around. Staff spoken with confirmed that they were comfortable with the present staffing generally although some commented that 'evenings can be busy'. Two people recently attending hospital have been escorted by staff.

Some concerns we received prior to our visit were centred around how the service keeps people safe within the current philosophy of care at Birch Abbey. We therefore looked specifically at indicators for how the service manages this. We did speak to people including relatives in a general sense and they told us that staff and the managers of the home are open to ideas and will address any issues that help to develop the service. We have a major concern however as the service has a high number of recorded accidents which they are not currently auditing to see if they can act to reduce these.

Archived: Birch Abbey

All Inspections

10 April 2018

During a routine inspection

6 & 7 January & 14 April 2016

During a routine inspection

16 & 17 June 2015

During a routine inspection

5, 6 June 2014

During a routine inspection

10 December 2013

During an inspection looking at part of the service

7 October 2013

During an inspection in response to concerns

30 July 2013

During a routine inspection

27 February 2013

During a routine inspection

12 April 2012

During an inspection looking at part of the service

29 March 2012

During an inspection looking at part of the service

9 January 2012

During an inspection looking at part of the service

6 October 2011

During an inspection looking at part of the service

6 June 2011

During an inspection in response to concerns