About the service:

Silver Birch Lodge is based in Aughton, near Ormskirk and provides accommodation for up to 31 older people, who require help with personal or nursing care needs. At the time of the inspection there were 21 people who lived at the service.

People’s experience of using this service:

The service had significantly deteriorated since the last inspection.

The provider failed to ensure individual risks for people who lived at the service had been assessed and this placed them at significant risk of avoidable harm.

Medicines were not managed safely and people did not always receive their medicines as prescribed.

People were not always risk assessed in relation to falls and weight loss this meant they were at risk of serious harm.

The provider had not ensured equipment such as bedrails were routinely checked for mechanical safety or that decisions made to use restrictive equipment were in line with people’s wishes or best interests.

We found the provider had not acted upon actions specified in a fire safety inspection report and therefore placed people at risk of avoidable harm in the case of fire. The provider did not have a suitable emergency evacuation procedure in place.

Staff were not always safely recruited. The provider did not always make sure checks were done in relation to suitability to work with vulnerable adults.

The service did not always support people in a person-centred way.

We found shortfalls in relation to the assessment of a person’s mental capacity before restrictive practices were considered. We also found a substantial lack of understanding from the registered manager and senior staff about the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS).

The provider did not ensure staff had up to date training to be able to provide safe and effective care.

The management and oversight of the service was poor. We found ineffective quality assurance systems and this meant that risks highlighted at this inspection had not already been identified by the provider.

The service was clean and people were protected by the prevention and control of infection.

Throughout the inspection we observed suitable numbers of staff deployed across the service and people who lived at the service and their representatives provided positive feedback about staff who supported them.

We observed staff interacted with people in a dignified and respectful way. People who lived at the service had access to meaningful activities and were encouraged to access the local community.

Rating at last inspection:

Our last inspection report for this service was published on 31 October 2018 and the rating was 'Requires Improvement' across all domains. There were three breaches of regulations 9,12,17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to person-centred care, safe care and treatment and good governance. The provider was also in breach of regulation 18 of the Health and Social Care Act 2008 Registration Regulations 2009, Notifications of other incidents.

Following the last inspection, we took enforcement action and issued the registered provider with warning notices in relation to medicines management, risk assessment and good governance. We also asked the registered provider to tell us what actions they would take to comply with these regulations.

At this inspection in February 2019, we found the provider had made some improvements in relation to the prevention and control of infection. However, we found continuing areas for improvement in relation to governance arrangements, risk assessment and medicines management. Our findings showed there were areas which had deteriorated further and areas that required further improvements and improvements made needed to be imbedded and sustained.

The service had deteriorated and was rated overall Inadequate.

Why we inspected:

This was a scheduled inspection based on the service's previ

Silver Birch Lodge was inspected on the 07 August 2018 and the 09 August 2018, the first day of the inspection was unannounced. Silver Birch Lodge is registered to provide personal care for up to 31 older people who require support with personal care and / or nursing care. At the time of the inspection there were 23 people receiving support.

Silver Birch Lodge 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.

Silver Birch Lodge is situated in a village location, near Ormskirk and Burscough. The home provides accommodation for up to 31 older people, who require help with personal or nursing care needs. Accommodation is all at ground floor level with easy access for those with mobility difficulties. Some bedrooms have en-suite facilities and direct access to the garden areas. There is parking available within the grounds of the home. A wide range of amenities are nearby within the village centre and public transport is easily accessible.

At the time of the inspection there was a manager who was registered with the Care Quality Commission (CQC). 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 comprehensive inspection was prompted by information of concern that people did not always receive care and support which met their needs, medicines were not safely managed and that documentation was not always accurate.

Our last inspection of Silver Birch Lodge was carried out in August 2017. This was a focussed inspection and we checked to see if medicines were managed safely and staffing arrangements were sufficient. We found no breaches of regulation in the regulations we looked at.

At this comprehensive inspection in August 2018 we found medicines were not managed safely and records relating to medicines were inaccurate. We also found people were not always supported in a safe way. We noted equipment was not always used safely to support people’s skin health and risk assessments were not always carried out to assess risk. In addition, the registered provider had not always worked with others in a timely way when responsibility for the care and treatment of people who lived at the home was shared with others. Staff told us they received training to enable them to carry out their roles. However, the registered provider had not ensured all staff had the skills and competence to support people safely. Infection control practices in the home required improvement to ensure people were protected from the risk and spread of infection. These were breaches of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Care planning had not always been carried out to ensure people’s needs and preferences were met. People could not be assured their individual preferences were recorded or that care planning would take place to ensure they received the support they required. We found the care of people at the home was not always person centred. We saw staff did not always encourage people to eat their meals. In addition, we found a person who required oversight when they were eating and drinking were not always observed by staff. This was a breach of Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Care records we viewed were not always complete. We found information was not always present in their care records to guide staff on the support people needed. Risk assessments in relation to the building were not always completed. This was a breach of Regulation 17 of the Health and Social Care Act

We carried out an unannounced focused inspection at Silver Birch Lodge on 18 July 2017. This was due to several anonymous 'whistle blowers' contacting the Care Quality Commission. Concerns were namely with regards to staffing levels being insufficient to meet the assessed needs of people at the home and with regards to medicines management. We did not find evidence to corroborate such claims during this inspection.

Silver Birch Lodge is situated in a quiet village location, near Ormskirk and Burscough. The home provides accommodation for up to 31 older people, who require help with personal or nursing care needs. Accommodation is all at ground floor level with easy access for those with mobility difficulties. Some bedrooms have en-suite facilities and direct access to the garden areas. There is ample parking available within the grounds of the home. A range of amenities are nearby within the village centre and public transport is easily accessible. At the time of the inspection there were 25 people living at the home.

At the previous inspection in November 2016 Silver Birch Lodge was rated as 'Good' overall with the safe domain receiving a rating of 'Requires Improvement'. There were no breaches of regulation but recommendations were made with regards to the environment in the laundry room and the used of a recognised staff dependency tool to ensure adequate staffing levels were in place. We found that the issues within the laundry had been remedied immediately following our previous inspection. However there was still no formally recognised staff dependency tool being used. At the time of our inspection there were six vacancies at the home and staffing levels were seen to be adequate.

The service had a registered manager in post at this inspection. 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 home was staffed to meet the assessed needs of the people living at the home. We found the home to be calm and relaxed and the people who lived at the home were clean and tidy in their appearance.

Medicines were managed appropriately. Staff who were responsible for administering medicines had received appropriate training and told us they were happy with the processes in place. Medicines were stored appropriately and the electronic recording system used was seen to be accurate.

Issues identified at the previous inspection with regards to the laundry had been resolved.

This unannounced inspection took place on 1 November 2016. We last inspected Silver Birch Lodge in September 2014. At that inspection we found the service was meeting the regulations that we assessed.

Silver Birch Lodge is situated in a quiet village location, near Ormskirk and Burscough. The home provides accommodation for up to 31 older people, who require help with personal or nursing care needs. Accommodation is all at ground floor level with easy access for those with mobility difficulties. Some bedrooms have en-suite facilities and direct access to the garden areas. There is ample parking available within the grounds of the home. A range of amenities are nearby within the village centre and public transport is easily accessible. At the time of the inspection there were 27 people living at the home.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run. The registered manager had notified the CQC of any incidents and events as required by regulation.

People living in Silver Birch Lodge told us that they felt “secure” and “safe” living there and relatives we spoke with told us they were “satisfied” with the care being provided. We spoke with people living at the home in their own rooms and with those who were sitting in communal areas. People told us that they felt they were being well looked after and staff listened to them. People told us the staff who supported them knew how they liked to be supported and always checked with them how they wanted to be helped.

People who lived at the home told us about the organised activities that went on in the home and their own interests that were supported. There was a programme of organised activities for people to take part in if they wanted to.

Relatives we spoke with told us that they did not have any concerns about how their relatives/friends were looked after and supported by the staff in the home. We saw that the staff offered people assistance but respected their independence. We saw that staff took the time to speak with people and took up opportunities to interact with them, engage and offer reassurance if needed.

People had a choice of meals and drinks, which they told us they enjoyed. People who needed support to eat and drink received this in a supportive and respectful manner. We saw that people were supported to maintain their independence as much as possible. We looked at the risk assessments in place for people and these included risk assessments for skin and pressure area care, falls, moving and handling, mobility and nutrition and for the management of a different conditions or the use of specific medication.

Systems were in place for the recruitment of staff and for their induction, training and development. Staff training relevant to the needs of the people living in the home was provided. Staffing levels were not being formally monitored to assess how many staff would be needed to support people according to their needs across all times of the day and night. We have made a recommendation that the service consider the use of a formal tool to help improve their continuous monitoring of staffing levels and to systematically assess the deployment and skill mix of staff needed across all shifts.

The staff employed were aware of their responsibility to protect people from harm or abuse. They knew the action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to a senior person in the home and that the registered manager was “approachable”. The service had in place a procedure to receive and respond to complaints and people told us they knew they cou

During the course of this inspection we gathered evidence against the outcomes we inspected, to help 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 those who used the service, their relatives, support staff and the manager and from looking at records. People who lived at the home and their relatives gave us positive responses to all the questions we asked and were able to outline what life was like at Silver Birch Lodge.

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 Silver Birch Lodge and their dignity was always respected. They were involved in making decisions about the care and support provided and felt all their needs were being met in an appropriate and safe way. People's individual needs were taken into consideration and they were able to move around the home freely and safely.

At the time of our visit to this location, we toured the premises and found the environment to be fit for purpose. It was safe, clean and hygienic. Equipment was well maintained and serviced regularly. Therefore, people were not put at unnecessary risk. Recruitment practices were robust. This helped to ensure only suitable people were appointed to work with this vulnerable client group and therefore helped to protect them from harm.

Is the service effective?

There was an advocacy service available. This meant that when required people could access additional support, if they wished to do so. The health and personal care needs of those who used the service had been assessed, with a range of people involved in their care and support. Specialist dietary needs had been identified, where required.

Systems were in place to ensure the home was effectively assessed, so the quality of service provided could be consistently monitored. A broad range of training modules were provided for staff, with regular mandatory updates. This helped to ensure the staff team delivered effective care and support for those who lived at Silver Birch Lodge. Visitors confirmed they were able to see people in private and visiting times were flexible.

Is the service caring?

We asked those who lived at the home and their relatives about the staff team. Feedback from them was very positive. They said staff were kind and considerate towards them and helped them to meet their needs. When we spoke with staff it was clear they genuinely cared for those they supported and were observed speaking with people in a respectful and friendly manner. People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

Staff were seen to be responding to people well by anticipating their needs appropriately. The home worked well with other agencies and services to make sure people received care and support in a consistent way. A range of external professionals were regularly involved in prescribing treatment for those who lived at the home, in accordance with their health care needs.

Evidence was available to show the home responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified.

Is the service well-led?

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 who lived at Silver Birch Lodge, their relatives and staff completed annual satisfaction surveys. Where shortfalls or concerns were raised these were taken on board and dealt with appropriately.

People living at the home and their relatives told us they were involved in decisions about their care. A relative said, “The manager always discusses the care with me. I am involved in everything”. People said they were treated with dignity and respect.

People had care plans that identified their personal care and nursing needs. Sufficient staff were on duty and people said their care needs were met. One person said, “If I need help I use the buzzer and it’s answered straight away”.

The home was clean, bright and comfortable throughout. People had their own rooms some people had personalised them with their own furniture and belongings. Safety risks were presented in some areas through the use of portable electric heaters and the lack of heat protection covers on radiators.

A complaints procedure was available. People said they would raise any concerns with the staff or the manager.

During our visit we spoke to five people living at the home, seven relatives, two care staff and the proprietor, who is also the manager of the home. We also spoke to a number of people who have cognitive impairment, however due to communication difficulties these conversations were brief.

Residents and their relatives spoke very highly of the staff team who were described as; “Outstanding” “Very good” and “Wonderful.” We observed staff carrying out their duties and saw that they were respectful, polite and considerate and that there appeared to be a good relationship between staff and those living at the home.

People are supported to maintain their religious beliefs. One person told us that ministers from the Catholic church visit him and another person told us that he has been supported to keep links with the nearby Anglican church.

The home is well managed and the staff team has remained stable. A relative told us; “Leadership is good, even when **** (the manager) is not here, it all runs smoothly.” And from another relative; “Nothing is too much trouble; we have full confidence in the staff.”

We were also told by relatives that they are able to raise any issues, concerns or suggestions, with full confidence that these would be listened to and acted upon.

An activity coordinator worked two days a week. People we spoke with did not think there was enough going on. One relative said, “Whilst (family member) may not want to get involved with what’s going on they would like to see something different.”

People we spoke with and some relatives said they were supported well and their needs were met. One person said, “If I need help and push the buzzer, staff come quite quickly.”

We saw records were kept of people’s fluid and food intake. These charts were used when people were at risk of not receiving enough nutrition. The charts we looked at were completed inconsistently.

When looking in the bathrooms we noted a number of repairs that had not been detected including; a missing bath panel and cracked flooring. Repairs left undetected leave a risk of potential harm to the people living in the home.

People we spoke with said they thought staff were competent in supporting them. One person said, “The staff are really nice, they are all terrific.” Another said, “The staff have taken the time to get to know me and they know what I like.”

The home did not have a comprehensive quality monitoring system in place. Some audits had taken place historically but none recently. The home had not monitored or audited, care plans medication or health and safety for some time. Not completing audits of this type did not give quality assurances the home provided an improving service.