This inspection took place on 5 April 2018 and it was unannounced. We last inspected the service on 2 and 21 February 2017, when we found breaches of regulations in relation to safe care and treatment, safeguarding service users from abuse and improper treatment and the proper and safe management of medicines. As the proper and safe management of medicines was, on that occasion a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, a warning notice was subsequently served.

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

This inspection took place on 02 and 21 February 2017 and was unannounced. We last inspected the service on 16 and 19 June 2015 and the service was judged to be in breach of five regulations.

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

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. A new manager has since been appointed to manage the location. Her application to the Care Quality Commission (CQC) has been submitted and is being processed.

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.

During our inspection we were able to speak with twelve people living at the home who, in general provided us with positive comments. They told us that they felt safe whilst care and treatment was being provided and their needs were being met by a kind and caring staff team.

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.

People we spoke with during our visit were very complimentary about the service provided.

They told us they were treated with respect and cared for in the way they wanted to be. They also said they felt safe living at Birch Green and the staff team were able to do their jobs well.

Comments received from people living at the home included:

"I am quite content. They (the staff) are very good, very, very good. They will do anything to please us."

"I like sitting here, where I can see people passing and I can watch the telly. My wife is in here too, you know and I can go down to see her at anytime. There are no restrictions at all I just please myself what I do."

" It is lovely and comfortable here, in a homely kind of way. The staff are very friendly and cannot do enough for us."

Birch Green Care Home is situated in Skelmersdale. It provides accommodation for up to 74 people who require help with 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.

This comprehensive inspection was unannounced and was conducted over two days.

On the first day of our inspection the registered manager was not on duty. 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. We were joined shortly after our arrival by the Managing Director and the Director of Quality and Compliance, who represented the organisation, Springhill Care Group Limited.

We found recruitment practices to be robust. Induction records for new staff were maintained. Agency staff also received a simplified induction programme before they started work. A wide range of training was provided and staff were knowledgeable about the needs of those in their care.

Assessments of people’s needs had not always been fully completed and relevant information was sometimes missing. However, we found the planning of people’s care and support to be person centred, providing staff with clear guidance about the needs of those who lived at the home and how these needs were to be best met. Risk assessments had been conducted, which were in general satisfactory. However, one we saw provided conflicting information for staff about an individual having swallowing difficulties and being at risk of choking.

People were helped to maintain their independence and although staff approached them and interacted with them in a gentle and friendly way, their privacy and dignity were not consistently respected.

We found that people’s dignity was not consistently promoted and their privacy was not always respected. However, we observed staff members approaching people in a kind, gentle and friendly manner and people were supported to maintain their independence as much as possible. People looked comfortable in the presence of staff members.

The staff team were confident in reporting any concerns about a person’s safety and legal requirements had been followed in relation to the Mental capacity Act 20015 (MCA) and Deprivation of Liberty Safeguards (DoLS). We have made a recommendation around this.

Accident records were appropriately maintained and these were kept in line with data protection guidelines. A contingency plan provided staff with guidance about what they needed to do in the event of an environmental emergency, such as power failure or severe weather conditions. Systems and equipment within the home had been serviced to ensure they were safe and fit for use.

We found that Medication Administration Records (MARs) had been appropriately signed when medications had been administered and any reasons for omission had been recorded. However, the overall management of medications could have been better. One person had not received two of their medicines for several days because the home had failed to order them in sufficient time. Receipts of medications into the home had not always been recorded and hand written entries on MAR charts had not always been signed, witnessed and countersigned in order to reduce the possibility of any transcription errors. On the first day of our inspection we noted one person’s medications were retained in a basket in her bedroom, which was easily accessible by other people. However, when we visited several days later this safety concern had been appropriately addressed.

Clinical waste was being disposed of appropriately. The layout of the home was well designed. Progress was being made towards adapting the environment on the first floor to be more suitable for those who lived with dementia. However, there were areas which needed attention in order to promote infection control practices and to make the environment consistently safe for people who lived at Birch Green.

Food served was tasty, nutritious and plentiful. The dining tables were pleasantly laid. However, the management of meals in one dining room was disorganised, but well organised in the other. A range of in-house activities were provided and outings to local places of interest were arranged, as well as visits from external entertainers.

We found eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for safe care and treatment, dignity and respect, good governance, person centred care and notifications of other incidents.

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