This inspection took place on 27, 30 April and 8 May 2018. The first day of the inspection was unannounced.

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

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

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

The service required and had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been in place since October 2015.

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

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

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

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

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

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

During the review and auditing of people’s care files, the home did not use information in people’s daily care records. This meant t

This inspection took place on 12, 17, 25, and 31 January 2016. The first two days of this inspection were unannounced. Birch Tree Manor is a large modern detached and purpose built building in a residential area of Port Sunlight, Wirral. The building is over two floors with well-kept courtyard style gardens. The home is registered to provide care and accommodation for up to 62 people. At the time of our visit 55 people were living at the home.

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

The home required and had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

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

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

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

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

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

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

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

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

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

We found that the service operated within the principles of the Mental Capacity Act 2005. Appropriate referrals had bee

Birch Tree Manor provides personal and nursing care within two units for a maximum of 62 people. The ground floor unit supports people with dementia the first floor unit supports people with nursing care needs. The service is situated in Port Sunlight Village, Wirral and is close to local amenities such as transport links, shops, museum, garden centre, pubs and cafes.

This inspection took place on 13 May 2015. The service was registered to provide accommodation for 62 people, there were 57 people living at Birch Tree Manor at the time of this inspection.

The home was registered to provide accommodation and care to people who may have nursing needs.

The home required a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008and associated Regulations about how the service is run.

At the time of this inspection the home did not have a registered manager. The current manager, who had registered manager experience, told us they would be applying for registration with CQC to become the registered manager for Birch Tree Manor. However at the time of writing this report no application had yet been made.

Birch Tree Manor was clean, bright and free from odours. However there was little signage around the service to identify different areas, especially to support people living with dementia.

People using the service had lived there for varying periods of time ranging from 1 week to 4 years.

People living at the service, staff, relatives and professionals that we spoke with were all positive about the service provided and people living there and relatives told us they felt safe.

We saw that there were effective recruitment procedures in place, complaints were dealt with effectively and staff performance issues were addressed appropriately.

Medicines were managed safely but we have made a recommendation about improving the care plans supporting the administration of some as and when required medications.

We found that the service was not effective in all areas as the mealtime experience would benefit from improvements and the environment would benefit from improved design and orientation to support people with dementia. We have made recommendations to support these findings

The staff in the home knew the people they were supporting and the care they needed. The staff were trained and competent to provide the support individuals required.

There was a calm, relaxed atmosphere within the home and good interaction between people using the service, staff and visitors.

The care plans that we reviewed showed that pre- admission assessments had been conducted and an agreement form had been signed by the service users which showed they been involved in their care planning. There was information available to enable people using the service to be supported in an individualised way that met their needs and people we spoke with knew how to make a complaint.

We carried out a responsive inspection of Birch Tree Manor because we had received information of concern. Concerns related to care and welfare, safeguarding, the environment, recruitment and staff support. We used the information received to check that people's care plans reflected their care needs and that care was being delivered accordingly. We also checked that risk assessments reflected people's individual risks and that they were reviewed and up to date.

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

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

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

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

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

We spoke with 10 people who lived at Birch Tree Manor about the care they received. People told us overall they were very satisfied with the care provided at the home. We were told “The staff look after me very well with respect and kindness”; “I am as happy as I can be"; “I think the staff know me very well” and “I feel very well supported” A relative told us “I am included in care planning” and another said “We are all very happy with the care”.

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

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

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

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

Concerns were raised with us about how people were cared for and the cleanliness of parts of the building. We looked at these issues as part of the inspection.

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

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

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

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

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