Archived: Birch Green Care Home

We found the following examples of good practice.

The upper floor had recently been refurbished and provided dementia friendly facilities. The bathrooms displayed handwashing posters which had been adapted to be dementia friendly. Staff had been given information on ‘mindful communication during COVID-19’ and posters were displayed in staff areas. Staff made adjustments to aid communication with people living with dementia whilst wearing personal protective equipment and these were reflected in the resident’s ‘face mask care plan’.

Staff facilitated visits for residents in line with guidance. Each resident had a visiting and communication care plan and well being coordinators took a lead in ensuring visits were booked and coordinated in a safe way. Visit slots were allocated in each area so staff could limit foot fall across communal areas as visitors arrived and left.

All areas of the home were visibly clean and tidy. Domestic staff took pride in their work and in maintaining strong infection prevention and control measures.

Staff completed risk assessments and care plans for residents for all aspects of their life which may be affected by COVID 19 such as visits outside the home, testing, vaccinations. Where residents lacked capacity to make decisions with regards to infection prevention and control measures appropriate capacity assessments and best interest decision making protocols had been followed.

Birch Green Care Home (Birch Green) is a residential care home providing personal and nursing care for up to 74 adults. At the time of our site visit there were 73 people living at the home.

The care home accommodates people over two floors, each of which has separate adapted facilities. The upper floor is served by a passenger lift and specialises in providing care and support for those living with dementia.

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

We assessed medicine practices within the home and found in general medicines were handled safely. However, some improvements were needed to ensure protocols for when required medicines included relevant information for the staff team. Medicine policies should also be specific to Birch Green and should cover the management of electronic records. We made a recommendation about this.

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

Safeguarding protocols were being followed and risks to peoples’ health and safety were being managed appropriately. This helped to protect people from harm. The environment was safe and well maintained and good infection control practices were being followed. One relative told us, “They [staff] bent over backwards to keep contact going [during lockdown]. They’ve done really well to protect staff and residents.” Another commented, “I know (relative) is safe. I can sleep at night.”

The provider had implemented robust recruitment practices and new staff had received a good induction period. The staff team were supervised, and a range of mandatory training modules were provided. One staff member told us, “We have a training officer on site. Staff are fully supported and trained to a high level. Carers are encouraged to further their careers with opportunities to become team leaders and assistant practitioners.”

Those who lived at the home and their relatives spoke highly of the managers and the caring attitude of the staff team. Staff we spoke with felt well supported by the managers of Birch Green. The management team was co-operative during the inspection process, providing information requested in an open and transparent way. The provider had implemented systems which helped to ensure the quality of service provided was assessed and monitored regularly and those with an interest in the service were supported to provide feedback so that improvements could be made as suggested. The registered manager was described as being ‘lovely’, ‘approachable’ and ‘fantastic- going above and beyond.’

Rating at last inspection

The last rating for this service was good (published 25 May 2018).

Why we inspected

We received a range of concerns about the management of the home, infection control practices, staffing levels and people's care, support and safety. As a result, we undertook a focused inspection to review the key questions of 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. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating 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 COVID-19 and other infection outbreaks effectively.

We found no evidence during this inspection that people were at risk of harm from the concerns raised. Please see the safe and well-led sections of this full report.

The overall rating for the service has not changed and remains Good. This is based on the findings at this inspection.

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

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

Follow up

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

Following that inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, caring, responsive and well led to at least good.

At this inspection we found the provider had made the improvements required in accordance with their action plan, so that the key questions of safe, caring, responsive and well led were found to be rated to at least good. During this inspection we found the service to be meeting the requirements of the current regulation.

Birch Green Care Home (Birch Green) is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection.

Birch Green is located in a residential area of Skelmersdale. Public transport links and local amenities are nearby. It provides accommodation for up to 74 people, who require support with nursing or personal care needs. There are two separate units, each of which has separate adapted facilities. One of the units specialises in providing care to people living with dementia. A passenger lift is available for easy access to the first floor. All bedrooms are of single occupancy and some have en-suite facilities. Bathroom and toilets are situated throughout the home. Ample parking spaces are provided.

At the time of our inspection there were 64 people living at Birch Green Care Home (Birch Green). We spoke with 17 of them and three family members or friends. The manager was on duty at the time of our inspection. She had been in post for a short period and was in the process of submitting her application to the Care Quality Commission to become the registered manager of Birch Green.

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 managing director of the organisation and general manager from another home within the company attended the inspection in order to support the manager of Birch Green.

At this inspection, we found that people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Mental capacity assessments had been conducted and Deprivation of Liberty Safeguards had been submitted to the local authority, as was deemed necessary.

We found recruitment and disciplinary procedures to be robust and these were being followed in day-to-day practice. People’s human rights were being protected and anti-discriminatory practices had been adopted by the home. This helped to safeguard those who lived at Birch Green.

Staff members were very knowledgeable about those in their care. We found the staff team to be well trained, through induction programmes, training modules, regular supervision and annual appraisals. Evidence was available to show staffing levels had recently been increased and that these were sufficient to meet the needs of those who lived at the home.

Although, additional minor issues in relation to medicines management were noted at this inspection, we found that overall medicines were being managed safely. However, we did make two recommendations about the auditing process of medicines and the storage of items in the drugs fridge.

Personal Emergency Evacuation Procedures (PEEPS), emergency plans and robust policies had been established. The premises were safe, well maintained and hygienic throughout. Significant improvements in the environment had been made since our last inspection. The home was very pleasant and suitable for those who lived at Birch Green. The dementia care unit was well designed to help with orientation and daily activity. This helped to maintain the safety and well-being of those who lived at the home.

Systems and equipment within the home had been serviced, in accordance with the manufacturer’s recommendations. This helped to ensure they were fit for use and therefore promoted the safety of those who lived at Birch Green. Accidents and incidents had been recorded appropriately and a wide range of robust risk assessments were in place.

A robust system was in place for monitoring the quality of service provided and it was clear the management team were open, transparent and visible during the inspection process. Action plans had been developed and lessons were learned when things went wrong and when improvements needed to be made. This helped to ensure the home provided a good quality of service for those who lived at Birch Green.

Records were retained in a confidential manner and those we saw were maintained to a good standard. However, those who lived at the home were able to easily access general information and records pertaining to themselves. The home would be able to produce information in various formats, should the need arise.

People’s needs had been thoroughly assessed and the care plans we saw were well written, person centred documents. However, some care charts were not always up to date. We made a recommendation about this.

Systems involving digital technology had been introduced and these enabled the service to move forward.

During this inspection we reviewed the action taken by the provider to meet the requirements of the regulations, these included; safe care and treatment including medicines management, environment safety and infection control. Person-centred care. Dignity and respect. Good governance including safe storage of confidential information and notification of other incidents.

At this inspection we found the provider was still in breach of the regulatory requirements for the proper and safe management of medicines. We also found a new breach of the regulations in relation to safeguarding service users from abuse and improper treatment. However the provider had made improvements around premises safety, infection control, person centred care, dignity and respect, storage of confidential records, governance and notification of other incidents.

Birch Green Care Home is situated in Skelmersdale. It provides accommodation for up to 74 people who require support with their personal or nursing care needs. There is a dedicated unit for those living with dementia. A passenger lift is available for easy access to the first floor.

All bedrooms are of single occupancy and some have en-suite facilities. Bathrooms and toilets are located throughout the home. Ample parking is provided and public transport links are nearby. Local amenities include a supermarket, shopping centre, pubs and cafes.

At the time of our inspection there were 58 people who lived at the service. There was a registered manager in place. The Registered Manager assisted throughout day one of the inspection and received initial feedback; however the registered manager was not available for the second day of the inspection so feedback was provided to the Nominated Individual and Head of Human Resources.

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.

A Nominated Individual is a person who has registered with the Care Quality Commission and must be employed as a director, manager or secretary of the organisation with responsibility for supervising the management of the regulated activity.

People told us they felt safe at the service and with the staff who supported them. The service had procedures in place for dealing with allegations of abuse. Staff were able to describe to us what constituted abuse and the action they would take to escalate concerns. Staff members spoken with said they would not hesitate to report any concerns they had about care practices.

Across both days of the inspection we found examples of reportable incidents recorded in people’s care records that had not been reported to the local Safeguarding Authority, this meant that the providers safeguarding procedures were not always being followed. We found the provider to be in breach of regulation 13 of the Health and Social Care Act 2014, safe guarding service users from abuse and improper treatment.¿

People’s needs were not always risk assessed against avoidable harm and injury. Care records showed general risk assessments were completed, however these were not always reviewed after a person had fallen or sustained an injury. ¿

The environment had been developed since our last inspection. Investment had been made and all areas within the service had been assessed for refurbishment and a schedule showed areas for decoration that had been achieved. A spacious modern bistro area had been developed on the ground floor unit and we observed people who lived at the service and their relatives access this area.

During the first day of inspection we advised the registered manager that some of the bedroom doors on the dementia care unit did not fully close, this meant that fire doors could be non- effective. Immediate action was taken to rectify the door closures. We also highlighted that the central sitting area within the foyer on the dementia care unit placed people at risk of falls. We observed people using the seating during the inspection and one person fell asleep and fell off the seat due to no side supports.

We found that staff recruitment was safe and staff were supported throughout their induction process. Staff told us that staffing levels were not sufficient on the dementia care unit at the weekend. We discussed this with the nominated individual who agreed to review staffing levels and the dependency of people who lived on the dementia care unit. The nominated individual told us that staffing levels were reviewed on a routine basis. We made a recommendation about this.

We found that medicines management systems were not robust and this meant that people were at risk of not receiving their medicines as prescribed. The provider had invested in a new electronic medicine system.

Records and certificates of training showed that a wide range of training was provided for all staff.

The provider was awarded a gold rating for Investors in People IIP in 2016. Following this success the Nominated Individual told us that staff were awarded a financial bonus to show appreciation from the company’s board of directors.¿

We found staff knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) was sufficient. The service had procedures in place for assessing a person's mental capacity in line with the MCA 2005 however records showed that processes were not always followed. We looked at 4 out of 10 people's care records which showed that the MCA 2005 had not been fully considered in relation to assessment of a person's mental capacity and consent to care.

We found that the service provided nutritious food and catered for people with specific dietary requirements. People were assessed on an individual basis and nutrition care planning showed people's needs and preferences. The service engaged with external health care professionals such as dieticians and speech and language services, when this was required.¿

We observed care practices in both lounge areas on the ground and first floor units. On the ground floor unit we found that staff engaged with people in a kind and dignified manner. People were encouraged to participate in activities and when they were not keen alternative activities were offered. On the first floor, we observed variable degrees of staff engagement with people living with dementia, some staff engaged with people in a person centred way, other staff failed to recognise when people tried to communicate with them. We observed five people attempt to communicate with staff and their attempts were ignored. Staff did not respond to non-verbal communication from the five people we observed. This meant that people’s needs were not always met in a timely manner and person-centred way.

We saw within people's care plans that referrals were made to other professionals appropriately in order to promote people’s health and wellbeing. Examples included referrals to social workers, pressure care specialists, physiotherapists and GPs.¿

Information about advocacy and other services was displayed around the service and staff were aware of the need for promoting advocacy and involving people’s next of kin when appropriate.

We looked at complaints management and found that the registered manager dealt with complaints in a timely manner and maintained robust records.

We found that people’s care plans had been written in a person centred way, however the service did not always ensure that care plans were updated when a person’s needs changed, for example after they had fallen or sustained an injury.

We looked at daily care records across both units. We found significant gaps in recording. This meant that the service did not always clearly demonstrate when a person had been supported with pressure care, nutrition and hydration, bowel care and personal hygiene.¿

We checked whether the service was committed to improving standards. The service had clear aims and objectives. The ethos of the service was made clear to people through the service’s aims and objectives and staff had a good understanding of the standards and values that people should expect.

The service was committed to staff development and was seen as a leading provider in the care home sector by an Investors in People award in 2016.

We found that the service had a quality auditing system in place. The Registered Manager carried out regular audits in areas such as, pressure ulcers, accidents and incidents, staff records, medication, cleaning, maintenance and care planning. We saw audits had been completed on a regular basis. However medication, care planning and accident/incident audits had not highlighted the concerns we found during the inspection. We made a recommendation about this.

We found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to safeguarding service users from abuse and improper treatment and safe care and treatment in respect of to individual risks to service users and the service continued to be in breach of the regulations in respect of the management of medicines. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

During the course of this inspection we gathered evidence against the outcomes we inspected to help to answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with eight people who used the service, five relatives, five support staff, the manager and provider. We also looked at a wide range of records.

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

Is the service safe?

People we spoke with told us they felt safe living at Birch Green and they were supported to maintain their independence as much as possible. We observed this to be done in a safe manner, so that people were not put at risk. Those who lived at the home also said their privacy and dignity was always respected and they were able to make decisions and choices about the care and support they received. We saw several very good examples of staff offering people choices throughout the day and supporting them to make a variety of decisions.

The home had proper policies and procedures in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. People were supported from outside agencies, if needed. For example, evidence was available to show advocates were utilised, if people wished to use this service, so that an independent person could act on their behalf. Those we spoke with told us that care and support was provided in a kind and caring manner, so that their needs were met in the way they preferred.

The recruitment practices adopted by the home were robust, which helped to ensure only suitable people were employed to work with this vulnerable client group. Systems were in place to help managers and the staff team to learn from untoward events, such as accidents, incidents and safeguarding concerns. This helped the service to continually improve.

Is the service effective?

The health and personal care needs of those who used the service had been thoroughly assessed. This helped the staff team to be confident they could effectively deliver the care and support needed by each person who moved into Birch Green Care Centre. People had been fully involved in planning their own, or their family members care, which promoted an effective person centred approach and helped to ensure care and support was delivered in the way individuals preferred. A wide range of external professionals were involved in the treatment of those who lived at the home. This meant that people's health care needs were being effectively met. However, the provider and manager told us work was being done around improving some areas of nutrition.

Systems were in place to ensure the practices and facilities were effectively assessed, so the quality of service provided could be consistently monitored and any shortfalls could be quickly addressed. Visitors confirmed they were able to see people in private and visiting times were flexible. This was observed during our visit. We saw people were constantly visiting their loved ones in the communal areas of the home or within the privacy of their own accommodation.

Is the service caring?

We asked those we spoke with about the staff team. Feedback from them was very positive. They said staff were respectful, kind and caring towards them and helped them to meet their needs. Those who lived at the home thought highly of the managers of Birch Green and were very complimentary about the staff team. One person we spoke with said, "The staff are brilliant. They are so compassionate." People's preferences and interests had been recorded well and care and support was provided in accordance with their wishes.

When speaking with staff it was clear they genuinely cared for those they supported and were observed speaking with people in a pleasant and friendly manner. One member of staff commented, "I really feel lucky to be working here. I love the residents and the people I work with. It's nice to wake up and want to come to work. I love my job."

Is the service responsive?

Staff were seen to be responding to people in a dignified manner, by anticipating their needs well. The service worked well with other agencies and services to make sure people received care and support in a consistent way. Evidence was available to show the home responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified. People completed a range of activities in and outside the service regularly, which were in accordance with their wishes and preferences.

Is the service well-led?

The manager of Birch Green had been in post for a short time only and therefore was not registered with the Care Quality Commission. However, she had submitted her application, which was being processed at the time of our inspection. Everyone we spoke with were very complimentary about the manager. One person who lived at the home commented, "She is just lovely" and a member of staff said, "Carol (the manager) is very approachable and we can talk to her about anything."

People who lived at the home felt they were respected as individuals and their needs were appropriately met by the staff team. The service had a quality assurance system in place and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result, the quality of service provided was continuously monitored.

Staff spoken with had a good understanding of their roles. They were confident in reporting any concerns and they felt well supported by the managers of the service. People living at Birch Green and their relatives completed satisfaction surveys. Where shortfalls or concerns were raised these were taken on board and dealt with appropriately.

We found staff to be well supported and appropriately trained and those living at Birch Green looked comfortable in their presence. We also spoke with two relatives who were all very complimentary about the staff team and the managers of the home.

Methods for monitoring the quality of service provided had been established and systems had been developed in order to protect the health and safety of those living at Birch Green.

Comments from those living at the home and some relatives included:

"It is smashing here. It is definitely home from home."

"I am very happy and content."

"The place is always spotless. They (the staff) are always cleaning and changing our beds."

"The staff look after us extremely well."

During our inspection we assessed standards relating to consent, care and welfare and how people were supported to be involved in the planning of their own care. We also looked at the cleanliness of the environment and the effectiveness of infection control. Standards relating to staffing levels, staff training and monitoring the quality of service provision were also inspected. We did not identify any concerns in any of the outcome areas we assessed.