We completed an unannounced inspection at the Birches on 8 November 2018. Birches is a care home and accommodates up to six people with a learning disability and or autism. On the day of our inspection, five people were living at the service.

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 service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy.

We carried out an unannounced comprehensive inspection of this service on 25 July 2017. Breaches of legal requirements were found and the service was rated as ‘Requires Improvement’. This was in relation to how staff were supported to provide effective care and support. People who used the service were found not to receive care and support that was based on their individual needs, interests and preferences. After the comprehensive inspection, we served a warning notice on the provider in relation to the governance of the service. The warning notice required the provider to become compliant with the legal regulation within a specified timescale. We inspected the service on 7 November 2017 and found the provider had made the required improvements in the governance of the service. This inspection reviewed if the provider was compliant with the two remaining legal requirements and how the fundamental standards of care were being met.

Since our last inspection, a new registered manager had been appointed and was available during the 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.

At this inspection we found the provider had made the required improvements in the breaches of legal requirements.

People were protected from abuse and avoidable harm because staff had received adult safeguarding training and followed the provider’s safeguarding policies and procedures. This included being aware of the provider’s whistleblowing process that supported staff to report any concerns of poor or abusive practice.

Risks associated with people’s needs, including the environment had been assessed and staff had clear and up to date guidance of the support required to manage known risks. People had complex needs and positive behavioural support plans were used, to provide staff with guidance of how to manage behaviours safely and effectively. Staff had received accredited refresher training in the safe practice of physical intervention and were clear, this was only used as a last resort and in the least restrictive way.

People were supported by staff who had been safely recruited to ensure, as far as possible, they were suitable to care for people. The staffing levels and deployment of staff considered staff skill mix and met people’s individual needs including wellbeing and safety.

Medicines management followed nationally recognised best practice. People received their medicines safely and in a way, they preferred. People’s medicines were reviewed by external healthcare professionals, to ensure they received the most appropriate medicine that met their needs.

People were protected from the risks associated with infections and cross contamination. Infection control practices were understood and followed by staff and the service was clean and hygienic.

Incidents were recorded, monitored and analysed to ensure p

We inspected Birches on 2 November 2017. The inspection was unannounced. The home is a situated in Newark in Nottinghamshire and is operated by CAS Learning Disabilities Midlands Limited. The service is registered to provide accommodation for a maximum of 6 people. There were three people living at the home on the day of our inspection visit.

We carried out an unannounced comprehensive inspection of this service on 25 July 2017. Breaches of legal requirements were found. After the comprehensive inspection we took action against the provider and issued a Warning Notice to ensure that improvements were made in relation to the governance of the service. The provider was required to be compliant with the notice by 2 October 2017. We undertook this focused inspection to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for the Birches on our website at www.cqc.org.uk.

Since our last inspection the registered manager had left the service. A new manager was in place and was in the process of submitting their registered manager application. We will monitor this. 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 provider had made significant improvements to the service and systems and processes in place to check on quality and safety were more effective. The breach in Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was found to have been met.

There was better oversight of the service by senior managers with increased accountability and scrutiny. The provider was committed to continue to maintain and develop the improvements made and had a sustainability plan in place.

Substantial improvements had been made to the governance of the service. Audit systems and processes for monitoring quality and safety had been reviewed and more robust procedures had been implemented.

People’s positive behaviour support plans had been reviewed and amended. These provided staff with clear guidance and support in managing periods of anxiety that affected people’s mood and behaviour. Incident forms used to record and monitor behavioural incidents had been reviewed and changed to support staff to record information more effectively. De-brief meetings with staff following any incident was completed to consider lessons learnt. An analysis of behavioural incidents showed a significant decrease. This was attributed to greater staff awareness and confidence in managing people’s behaviours, increased staffing levels that supported people to be more active, good leadership by the manager and support from the provider’s clinical team.

People who used the service, relatives and external professionals received opportunities to feedback their experience about the service.

Staff had received refresher training on particular areas such as safeguarding and managing behaviours and their competency and understanding was monitored and reviewed. Staff had received opportunities to discuss their work and development needs and there was an ongoing supervision and appraisal plan in place. Staff meetings were more frequent and used effectively to drive forward improvements. Staffing levels had increased and this had a positive impact on people who used the service.

Improvements had been made to the external and internal environment, including redecoration and new furnishings and equipment.

The service was last inspected in November 2016 and was rated 'Good' overall. This inspection was brought forward due to some concerns we had received about how risks were managed.

This unannounced inspection was carried out on 25 July 2017. The Birches is registered to provide accommodation and personal care for up to eight people with a learning disability and autism. On the day of our inspection visit there were four people who were using the service.

The service had a registered manager in place at the time of our 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.

People may be left at risk of harm or abuse because the procedures designed to protect them were not followed. People may be left at risk because staff were unsure of practices to follow.

There were not always enough staff available to provide people with the support they needed to have an active and full life. People’s medicines were managed safely although they may not be given these in a timely way when they were needed.

Staff did not have all of the training they needed for their role and they did not feel they had the support they required. People’s rights may be overlooked as the Metal Capacity Act (2005) was not always followed. People had their freedom lawfully restricted when this was needed for their own safety.

People were able to follow a healthy diet but did not always choose to do so. Staff understood people’s healthcare needs and their role in supporting them with these.

People were supported by staff who cared for them and treated them with dignity and respect. People who used the service and their relatives could have more involvement in planning and reviewing their care.

People’s care and support was not carefully planned to ensure they received this in the way they needed it and have opportunities to work towards individual goals and aspirations. People were supported by an advocate who would speak up on their behalf and raise any concerns or complaints.

People used a service that did not have a cohesive staff team which did not work together to provide the best support possible. The leadership did not inspire and develop staff. Quality monitoring systems had not identified and driven improvements in the service.

During this inspection we found concerns two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We inspected the service on 10 November 2016. The inspection was unannounced. Cambian Birches provides care and support for up to six people with a learning disability and autism. On the day of our inspection four people were using the service.

The service had a registered manager in place at the time of our 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.

People were supported by staff who knew how to recognise and respond to abuse and systems were in place to minimise the risk of harm. Risks associated with people’s care and support were effectively assessed and managed.

Medicines were managed safely and people received their medicines as prescribed. People were supported to eat and drink enough. People had access to healthcare and people’s health needs were monitored and responded to.

People were supported by staff who had the knowledge and skills to provide safe and appropriate care and support. There were sufficient numbers of staff available to meet people’s needs. Safe recruitment practices were followed and staff were provided with regular supervision and support.

People were supported to make informed decisions and where a person lacked capacity to make certain decisions they were protected under the Mental Capacity Act 2005. People were supported in the least restrictive way possible and staff were insightful about how to support people who presented behaviours which may challenge others.

People were provided with information in a way that was accessible to them and staff had a very good understanding of how people communicated.

Staff were kind and compassionate and treated people with respect and people’s rights to privacy and dignity were promoted and upheld. People and their families were supported to raise issues and staff knew how to deal with concerns if they were raised.

Where possible people and their families were involved in planning their care and support, staff knew people’s individual preferences and tailored support to meet their needs. People were enabled to make choices about their care and support and encouraged to be as independent as possible.

People led full and varied lives and were supported to have a social life and to pursue their interests and passions.

The service had a warm, friendly and open atmosphere and staff and managers were passionate about enabling people to have good lives. People using the service and staff were involved in giving their views on how the service was run and there were effective systems in place to monitor and improve the quality of the service provided.

This inspection took place on 09 December 2014. Cambian Birches provides residential care for up to eight young people and adults with autism and learning difficulties. On the day of our inspection four people were using the service.

The service had a registered manager in place at the time of our 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 and associated Regulations about how the service is run.

Staff had received training in keeping people safe and they knew how to raise any concerns if they suspected someone was at risk of harm or abuse. Staff understood the risks people could face through everyday living and how they needed to ensure their safety.

There were sufficient staff to provide people with the support they needed to live as full a life as possible. People also had the support to take any medicines they needed.

People made choices and decisions where they were able to, but where they were not able to make their own decisions about the care they received decisions were made in their best interest. Staff were made aware of what their work would involve and the skills they would require before taking up employment. They received training and supervision to ensure they had the knowledge and skills to provide people with safe and appropriate care.

People were encouraged to eat well and supported to have their required nutritional intake. People received support with their healthcare in a way that most benefited them.

People were treated with respect and had their privacy and dignity promoted. People received encouragement to be independent where they were able to be. Staff understood the best way to communicate with people and to how involve them in what they were doing.

People spent their time doing things they enjoyed and had opportunities to learn and develop new living skills because staff followed people’s individual plan which provided them with this information.

The management of the service was open and approachable. Imaginative ways were found to enable people who used the service to express their views. There were systems in place to monitor the quality of the service provided.

Prior to our inspection we reviewed all the information we had received from the provider. Because people using the service had complex needs they were not able to tell us about their experiences of living at the home. We therefore used a number of different methods to help us understand the experiences of people residing at the home. We observed staff interacting with the residents and spoke with a relative of one person who was visiting the home on the day of our inspection to establish their views on the quality of service provision. We also spoke with the registered manager, the deputy manager and an activities coordinator.

The relative of a person who was using the service told us that they were happy with the quality of service provision and felt the care staff promoted people’s respect and dignity.

We found that care staff were provided with comprehensive details about peoples' individual needs and preferences in relation to the type of support they were provided.

We found that effective recruitment processes were in place and staff had received a training package pertinent to their roles and responsibilities.

Quality auditing procedures were undertaken and systems were planned for gathering, recording and evaluating information about the quality of the service provided.