The inspection took place on 2 and 4 May 2018, it was unannounced on the first day and announced on the second day.

At the last inspection in May 2017 there were no breaches of regulation. We rated the effective and well-led domains as ‘requires improvement’ which meant the quality rating was 'requires improvement' overall. This is the third consecutive time the service has been rated Requires Improvement. We found quality assurance checks and audits had been improved and staff understood the need to gain consent before care and support was provided. However, the principles of the Mental Capacity Act 2005 were still not followed or implemented in a consistent way.

The service is required to have a registered manager in place. 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 2008 and associated Regulations about how the service is run. There was no registered manager at the service, an acting manager had been in place for five days.

The Birches 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 care home accommodates people across four bungalows and two self-contained flats. Three bungalows (Birchdale, Birchwood and Birchwalk) having eight bedrooms and one bungalow (Birchrise) which has four bedrooms. All bungalows could be accessed via a secure door leading from one to another, but each bungalow was treated as a separate entity. There were two self-contained flats, only one was occupied at the time of the inspection. There were 26 people with learning disabilities or autistic spectrum disorder living at the service.

The care service has been developed in some areas in line with the values that underpin Registering the Right Support. (This guidance clarifies the expectation on providers to ensure care homes are focused on person-centred care and developed in line with national policy). We found the bungalows were separate units, even though they were all based at one location. Registering the Right Support values include choice, promotion of independence and inclusion for people living with learning disabilities and autism to ensure they can live as ordinary a life as any citizen. Further work needs to be undertaken once the breaches of regulation have been addressed to ensure the service complies with Registering the Right Support.

During this inspection we found issues with the environment. During our walk round of each bungalow we found issues with the environment which had to be addressed to help to maintain people’s safety. The acting manager took swift action to address the environmental issues we found. However, we recommend that the provider should monitor the environment to make sure it remains safe for people.

We found the administration and management of people's medicines was not always effective to ensure people's medicines were returned, recorded or stored appropriately. We recommend the provider follows good practice guidance in relation to medicine management.

The principles of the Mental Capacity Act 2005 (MCA) were not followed. Decisions were not made in accordance with the MCA. Associated records lacked detail; they were generic and not person-centred. Best interest decisions were not always completed following capacity assessments, which contravened the MCA. This meant that people who used the service had limited choice and control about their lives and experienced unnecessary restrictions.

We found people’s care records were excessive, not easy to follow and staff had made changes to care records without dating or signing entries. It was unclear from people’s care records wha

The Birches is a purpose built facility owned by Humberside Independent Care Association, a not for profit organisation. The service provides care and accommodation for up to 31 adults with a learning disability. Accommodation comprises of single bedrooms set within individual bungalows with communal sitting and dining areas.

The service 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.

At the last comprehensive inspection on 19 and 20 January 2017, we rated the service as Requires Improvement overall. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we saw evidence to confirm that the registered provider had taken appropriate action and achieved compliance.

People who used the service were protected from abuse and avoidable harm by staff who had been trained to recognise the signs of potential abuse and knew what actions to take if they suspected abuse had occurred. Staff who had been recruited safely were deployed in suitable numbers to meet the assessed needs of the people who used the service. People’s medicines were managed safely and administered as prescribed. People were cared for in a clean, hygienic and well maintained environment. Staff understood how to minimise the potential for cross contamination and wore personal protective equipment when required.

People were supported by staff who had completed a range of training and nationally recognised qualification in health and social care. Staff told us they received effective levels of support and annual appraisals. People were supported to eat a balanced diet of their choosing. When concerns were identified relevant professionals were contacted for their advice and guidance. The registered manager was aware of the responsibility in relation to the Deprivation of Liberty Safeguards and had submitted applications for a number of people who used the service. However, the principles of the Mental Capacity Act were not followed or applied consistently. After the inspection we received information from a regional director and the registered manager about the actions that would be taken to rectify this.

People were supported by caring staff who knew their needs and preferences for the care and support they required. During our observations it was apparent that caring and supportive relationships had been developed between the staff and the people who used the service. People’s privacy and dignity was respected and promoted. Staff understood the importance of treating private and sensitive information confidentially.

People or their appointed representatives were involved with the initial and on-going planning of their care. People’s levels of independence and strengths and abilities were recorded. People were encouraged to take part in activities and to follow their hobbies and interests. The registered provider displayed their complaints policy within the service and provided it to people at the commencement of the service to ensure it was accessible. We saw evidence to confirm when complaints were received they were investigated and responded to in line with the registered provider’s policy.

Quality assurance systems and processes had been developed to ensure shortfalls were identified and action was taken without delay. People who used the service and their relatives were asked to provide feedback on the service and their opinions were used to make improvements when possible. The registered manager understood and fulfilled their responsibilities to report accidents and incidents as well as other notifiable events to the Care Quality Commission as required.

The Birches is owned by Humberside Independent Care Association, a not for profit organisation. The service provides care and accommodation for up to 31 adults with a learning disability. Accommodation is provided for people in four bungalows and two self-contained flats. All rooms are single occupancy and there is access to dining and seating areas with domestic style kitchens available.

This inspection of The Birches took place on the 19 and 20 January 2016 and was unannounced. There were 28 people living at the service at the time of this inspection.

When we last inspected the service on 22 April 2016 we found the provider was not meeting the required standards and that they were in breach of regulation 15, premises and equipment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvements were needed to ensure the environment was well-maintained. The registered provider sent us an action plan to tell us the improvements they were going to make. At this inspection we found that the registered provider had not addressed all the concerns we had at our last inspection. We found that sufficient actions had not been taken in relation to maintaining the environment and the service continued to be in breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found four new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to staffing, management of medicines, infection control, maintenance of the environment and the systems for assessing the quality of the service provided. You can see what action we told the provider to take at the back of the full version of the report

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

At this inspection we found that people's medicines were not always managed safely.

We found at times there were not enough staff to meet the needs of people who used the service during the night. Four care staff were indicated on the rota, however we saw over a three month period prior to this inspection on 13 occasions only three staff had been deployed. The registered provider addressed this during the inspection and gave us assurances that a minimum of four staff would be on duty during the night. We found that some people who used the service had reduced opportunity to access the community due to staffing levels during the day. The registered provider has agreed to re-assess people’s support needs and staffing levels to look at this and make improvements.

We found a number of infection control and maintenance issues that required attention at the service. These included toilet flooring lifting in areas, worn toilet seats, a dirty expel air and significant dirt and dust under radiators.

The registered provider’s quality assurance systems were not effective. They failed to highlight the areas of the service that required improvement and were not used to ensure action was taken to rectify known issues in suitable timescales. There were a number of systems in place in the service but these were not sufficiently robust to identify the shortfalls we found during the inspection. The registered manager and other representatives of the organisation had completed audits to monitor the quality of service and we saw these had highlighted some of the issues identified during our inspection. We saw these had not been addressed in a timely manner. Therefore they were ineffective at driving improvements.

CQC is required to monitor the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in plac

The Birches is a purpose built facility owned by Humberside Independent Care Association, a not for profit organisation. The service provides care and accommodation for up to 31 adults with a learning disability. Accommodation is provided in two fully equipped self-contained flats and four bungalows. All rooms are for single occupancy with access to sitting areas, dining areas and domestic style kitchens.

We undertook this unannounced inspection on the 22 April 2016. At the time of the inspection there were 27 people using the service.

The service had a registered manager in post. 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.

Improvements were needed to ensure the environment was well-maintained. This was a breach of Regulation 15(1) (e) of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the back of the report.

We found there were policies and procedures in place to guide staff in how to safeguard people who used the service from harm and abuse. Staff received safeguarding training and knew how to protect people from abuse. Risk assessments were completed to guide staff in how to minimise risks and potential harm. Staff took steps to minimise risks to people’s wellbeing without taking away people’s rights to make decisions.

We found people’s health and nutritional needs were met and they accessed professional advice and treatment from community services when required. Staff kept a log of when people had contact with health professionals in the community. People who used the service received care in a person -centred way, the care plans described their preferences for care and staff followed this guidance.

Positive interactions were observed between staff and the people they cared for. People’s privacy and dignity was respected and staff supported people to be independent and to make their own choices. Staff provided information to people and included them in decisions about their support and care.

We found staff were recruited safely and were employed in sufficient numbers to meet people’s needs. Staff had access to induction, training, supervision and appraisal which supported them to feel skilled and confident when providing care to people.

Medicines were, stored, administered and disposed of safely. Training records showed staff had received training in the safe handling and administration of medicines.

People who used the service were seen to engage in a number of activities both within the service and the local community. They were encouraged to pursue hobbies, social interests and to go on outings. Staff also supported people to maintain relationships with their families and friends.

Menus were varied and staff confirmed choices and alternatives were available for each meal; we observed drinks and snacks were served between meals. People’s weight was monitored and referrals to dieticians made when required.

Staff had received training in legislation such as the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and the Mental Health Act 1983. They were aware of the need to gain consent when delivering care and support and what to do if people lacked capacity to agree to it. When people were assessed by staff as not having the capacity to make their own decisions, meetings were held with relevant others to discuss options and make decisions in the person’s best interest.

People had assessments of their needs and plans of care were produced; these showed us people and their relatives had been involved in the process. We observed people received care that was person-centred. They were able to bring in items from home to make

People who used the service had very complex needs relating to their learning disability and/or health conditions. We found that some people were unable to give us a detailed account of their experience of the service due to their limited communication. We spent time speaking with people and observing the care provided to gather information about people's experiences.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People who used the service told us they were satisfied with the care and support they received. Comments included, “I feel good about living here, I like it.” Staff were knowledgeable about people's care needs and we observed very positive interactions between staff and people who used the service.

People were supported to be able to eat and drink sufficient amounts to meet their needs and were provided with a choice of suitable and nutritious food and drink. People told us they enjoyed the food provided. Comments included, “We get plenty of food and we get a good choice.”

There were appropriate arrangements in place to manage medicines.

The environment was suitably designed and clean and tidy but one area was not adequately maintained. We have received written confirmation that the work to improve this area will be completed in a timely manner. There was adequate equipment provided to meet peoples needs.

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. People we spoke with couldn't remember if they had signed to agree to their care plan. However they confirmed that staff spoke to them about the care they required and agreed this with them before supporting them with their care. One person told us "Yes we have a care plan and staff talk to us about different things like, what you like doing; we have a choice."

We found people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People who used the service told us they were satisfied with the care provided and that their needs were met.

We found the environment that was suitably designed and adequately maintained. People told us they liked their rooms and had helped to choose the decor. They told us "It's good living here", "I feel safe here, it's nice and quiet" and "I like living here."

We found staff received appropriate training and support. People told us they liked the staff and they said their needs were met. They told us "The staff are very nice" and "The staff are good, they are all nice."

People were made aware of the complaints system.This was provided in a format that met their needs. People told us they could raise issues if they were not happy.

Some people living at the home had complex needs and were not able to verbally communicate their views and experiences to us. Due to this we have used a formal way to observe people in this review to help us understand how their needs were supported. We call this the ‘Short Observational Framework for Inspection (SOFI).

Throughout the observation we saw all staff treat people with respect and courtesy. The atmosphere in the home was relaxed and during our observation we saw positive and friendly interaction between staff and people who use the service. We observed periods where staff and people who use the service were singing and dancing in one of the communal sitting areas.

Some people that we spoke with told us they were happy living at the home and we received comments such as “I like it here” and “We are always going out”.

The Birches is a purpose built facility owned by Humberside Independent Care Association, a not for profit organisation. The service provides care and accommodation for up to 31 adults with a learning disability. Accommodation comprises of single room bedrooms set within four bungalows with communal sitting and dining areas.

There was a registered manager in post at the service. 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.

This inspection was unannounced and took place over two days. The last inspection of the service took place on 7 November 2013, no issues were identified.

Policies and procedures in place to protect people from harm or abuse. Training records showed staff had been trained in what abuse was and how to identify and report it. Staff told us the management were responsive to any safeguarding concerns they may have.

Care plans contained up-to-date and appropriate risk assessments for medication; pressure care; falls; nutrition; the safety of wheelchairs; the environment; and behaviour which may challenge the service.

The 30 people who used the service were cared for by 11 support workers throughout the day. In addition, extra support workers were employed throughout the day to provide specific one to one sessions with some people who used the service.

Medicines were stored, administered and disposed of safely. At the time of our inspection visit no controlled drugs were kept at the service. Training records showed the senior staff had received training in the safe handling and administration of medicines. Staff administering medicines also received an annual check of their competency.

The service was clean and tidy. We saw one bathroom in the Birchrise unit was in need of some decoration as a priority. The registered manager told us the bathroom would be redecorated at the earliest opportunity.

Staff told us they had been trained in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). Records confirmed this.  These safeguards provide a legal framework to ensure that people are only deprived of their liberty when there is no other way to care for them or safely provide treatment. At the time of our inspection no one was subject to a DoLS authorisation.

Staff were able to describe how they would deal with people who sometimes demonstrated behaviour that challenged the service and others.  We saw behaviour management plans were put in place for some people and monitoring charts were used when appropriate.

The service’s training records showed the courses staff had undertaken and when they were due to be refreshed. Training was up-to-date. Staff told us they received supervision approximately every six weeks.

We observed the lunchtime experience and saw that a number if meal options were available for people to choose from. Lunch appeared appetising and was served without delays meaning the meal remained hot and everyone could eat at the same time.

The service identified changes in people’s needs effectively through the monthly review of care plans. We saw the service had sought input from health and social care support agencies; for example, occupational therapists, clinical psychologists and the community team for learning disability (CTLD).

We observed staff consistently interacting with people. Some staff were engaged in providing one-to-one sessions with some people who used the service. Others were available in the communal areas. Staff we spoke with were able to describe people’s life histories and clearly knew and understood people’s social preferences.

We saw the service supported people to express their views through a quarterly ‘My review’ meeting. This meeting took place between the person, their key worker, and a member of the service’s management.

Care plans we reviewed were easy to read and were written around the needs of the person as an individual. However, we saw the care plans were not consistently ordered which meant some information was hard to find. We saw care plans had been routinely reviewed on a monthly basis to ensure people’s choices, views and health care needs remained relevant to the person.

We noted people’s involvement in activities were recorded in daily progress notes. We saw people who used the service had been encouraged to participate in a number of activities in order not to become socially isolated.

Leadership and management of the service were good. There were systems in place to effectively monitor the quality of the service and drive a culture of continuous improvement. Staff told us there was good communication between them and the management.