The inspection took place on 13 and 15 December 2016 and was an unannounced inspection.

Birch Trees Nursing Home provides accommodation and nursing care for up to 22 older people. At the time of our visit, there were 20 people in residence. The home is situated in a rural location, close to the town of Midhurst. Accommodation is provided over two floors and is accessible by a lift and stair lift. Communal areas include a dining room and lounge on the ground floor. There is a large garden accessible to people at the back of the home.

The service has 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.

People and relatives spoke positively about the service. They said that it was welcoming and that people received a high standard of care. There was a regular team of staff who knew people well. Staff were supported by the registered manager and representative of the provider who were regularly in the home. Feedback was welcomed and the registered manager was proactive at trying new ideas and making improvements to the care that people received.

People felt safe at the service and there were enough staff to respond to their needs. Staff understood local safeguarding procedures. They were able to speak about the action they would take if they were concerned that someone was at risk of abuse. Risks to people’s safety were assessed and reviewed. People received their medicines safely.

People had developed good relationships with staff and had confidence in their skills and abilities. They told us that staff were kind and that they treated them respectfully. Staff had received training and were supported by the management. Staff were able to pursue additional training which helped them to improve the care they provided to people.

People were involved in planning their care and in making suggestions on how the service was run. Staff understood how people’s capacity should be considered and had taken steps to ensure that people’s rights were protected in line with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

People enjoyed the meals at the service and were offered choice and flexibility in the menu.

Staff responded quickly to changes in people’s needs and adapted care and support to suit them. Were appropriate, referrals were made to healthcare professionals, such as the GP or Community Psychiatric Nurse (CPN), and advice followed.

A variety of activities were provided, both in the form of group and individual interests.

There was strong leadership within the home. The registered manager and representative of the provider monitored the delivery of care and regularly assisted staff in supporting people. They had a system to monitor and review the quality of the service and were prompt in taking action if improvements were identified.

This inspection was carried out by an adult social care inspector. The focus of the inspection was to check if the provider had taken sufficient action to meet the compliance actions set at our visit in January 2014. We considered our inspection findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

This summary is based on our observations during the inspection, discussions with four people, two relatives, the manager, the provider, one nurse, three care staff, two housekeeping staff, the chef and the activities coordinator. We also reviewed records relating to the management of the service and five people's care and health records. As some people could not talk with us about their experiences of living at the service we spent time observing how they were cared for and treated by staff. We observed interactions between staff and people who lived at the service for one hour during the morning and lunchtime period.

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

Is the service safe?

People had care plans that were detailed and provided up-to-date information about their care needs. The care plans that we looked at demonstrated that people or their representatives had been consulted and that their personal needs and preferences were reflected. We found that the service had taken action to identify shortfalls in record keeping identified at our last inspection. Records that we looked at were accurate and fit for purpose.

The service had also taken action to address the concerns over cleanliness and infection control identified at our last visit. We found that the people were cared for in a clean, hygienic environment. One person told us, “It’s very clean this place”. Another said, “It’s spotlessly clean”.

The service had appropriate systems in place to manage medicines. Medicine was stored, administered, recorded and disposed of in a safe way.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, the manager demonstrated knowledge of their responsibilities in respect of this.

Is the service effective?

We found that people’s care plans were detailed and that they had been reviewed on at least a monthly basis. This helped to ensure that the care provided was in line with people’s current needs. One relative wrote to us and said, ‘Arrangements are truly flexible to suit the needs and wishes of the residents. Nothing seems to be too much trouble here’.

As many of the people living at the service were unable to speak directly of their experience, we spent time observing the care and support that they received. Staff demonstrated skill and experience when supporting people. One person told us, “The staff are ever so good”. Another said, “The people are nice, everything is super”. A relative shared, “I go home and I know X is well taken care of. I’ve got nothing but praise for them”

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. We spoke with five people. They were all satisfied with the care that they received. They told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us, “I couldn’t have come to a nicer home; I class myself as very lucky”. In a letter from a relative to the provider we read, ‘The way in which you all diligently care for people’s every need without question and with great patience and professionalism is remarkable’. They also referred to the ‘Genuine love and affection’ of the staff. The manager told us, “We’re very proud of our staff”.

Is the service responsive?

People told us that they were able to raise suggestions or concerns and that they were consulted about changes in the service. Relatives told us that they were kept informed and updated if there were any issues or concerns regarding the health of their family member. One relative said, “I often get a phone call, for example if X has fallen over or has a cold. They always let me know”. We found that the service listened and responded to questions and feedback received from people, their representatives and from staff.

Is the service well-led?

Since our last visit improvements had been made in the way the service managed infection prevention and control. There had also been improvements in the accuracy of people’s recorded care needs.

The manager and provider were available at the service and were able to respond quickly to any concerns or suggestions. The manager had a system of quality assurance which included regular audits. We noted that action plans were in place that detailed steps to address any identified shortfalls. This meant that systems were in place that ensured that the quality of service was regularly monitored and assessed. One relative told us, “Everything is well managed”.

Systems were in place to make sure that the manager and staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

We spoke to three people living at the service; one person told us "it's nice here".

When we spoke with visitors in the home, we were told: "the staff are lovely" and "my relatives fairly new here". We were told that staff at the home were very welcoming.

We found evidence that the people using the service were not protected from the risk of healthcare related infection and the provider did not have effective systems in place for managing the risks of healthcare related infections.

Staff were only employed following a structured recruitment and interview process and relevant checks were carried out prior to them starting work.

On the day of our visit there were seventeen people residing in the home. They were all elderly and frail and many were suffering from dementia or Parkison’s disease. The service was managed by the registerd owner and his wife, and both of them were qualified nurses.

We were unclear to the extent that people and their relatives were involved in decisions relating to their care and treatment, but we found that they were being treated with respect and dignity, and that there were a range of activities available to them.

We looked at the care of people in the home and found that people and their relatives were generally happy with their care, and that there was an effective care planning process in operation.

We looked at safeguarding and found that the provider was taking steps to ensure that people were protected from abuse, although we thought the whistleblowing policy could have been strengthened.

We looked at staffing and support for staff and found that on the whole there were a sufficient number of properly qualified staff in the service, although this was queried by one staff member we spoke to. We also found that staff received proper training, supervision and appraisal.

Finally we looked at the assessment and monitoring of the service and found there were procedures for doing this, although the evidence of a regular and systematic process was somewhat limited.