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

Birchmere House provides residential and nursing care to older people. The home has three floors accommodating up to 76 people in one adapted building. On the day of our visit 53 people lived at the home and two of these people were in hospital. The home is located in Solihull, West Midlands.

Recently, the service provision changed. The provider for the home is now two separate companies with joint responsibility for the home. The name of the service also changed from ‘Birchmere’, to 'Birchmere House'. The changes in registration delayed the publication of this report.

Our last inspection took place on 29 September and 17 October 2016. This inspection was a focussed responsive inspection where we looked at the key questions of ‘safe’ and ‘well-led’.This was in response to information we had received in relation to people's safety and how risks were managed, particularly in the reminiscence area for people living with dementia. However, since that inspection the providers have closed the reminiscence area of the home and the maximum occupancy at the home has reduced from 131 to 76. Prior to this, our last comprehensive inspection where we looked at all five key questions of safe, effective, caring, responsive and well-led, was March 2016.

At the focussed inspection we found there was one continued breach of regulation 17 (Good governance) associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014. The home was rated as ‘Requires Improvement’. This was because further improvements were required to establish systems and processes and to complete accurate and up to date records of each person’s care and treatment.

The provider sent us an action plan which stated all the required improvements would be completed by 20 May 2017. During this inspection we checked whether the improvements had been made and we found sufficient action had been taken in response to the breach in regulation.

There was a registered manager at the home. They had started work at the home in June 2017 and registered with us in December 2017. 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 felt safe living at Birchmere House and there were enough staff to support their care needs in a timely way. Procedures were in place to protect people from harm. The staff and the registered manager understood their responsibilities to keep people safe. Staff had received training in ‘safeguarding adults’ to protect people from harm and described to us the signs which might indicate someone was at risk.

Processes were in place to keep people safe in the event of an emergency. People had personal fire evacuation plans and staff understood the actions they needed to take in the event of an emergency. Accidents and incidents that happened in the home were monitored and action was taken to reduce the risk of reoccurrence. Checks took place to ensure the environment and equipment was safe to use.

The provider’s recruitment procedures minimised risks to people’s safety. Recruiting new staff had been one of the provider’s priorities over the previous six months to ensure people received consistent care from familiar staff. New staff received effective support and training when they started working at the home. Staff had completed the training they needed to be effective in their roles.

Risk assessments identified potential risks to people's health and wellbeing. Staff had a good knowledge

Sunrise Operations Knowle Limited is registered for a maximum of 131 people offering accommodation for people who require nursing or personal care. At the time of our inspection there were 109 people living at the service. The home is divided into two areas, Assisted Living and Reminiscence. The Reminiscence area is for people living with dementia.

At our last comprehensive inspection in March 2016, we found there was a breach in the legal requirements and Regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to good governance. Systems and processes to monitor and improve the quality and safety of services provided, and to manage risks related to the health, safety and welfare of people, were not established. This included records not always being sufficiently detailed and accurate to support safe and appropriate care.

We asked the provider to take action to improve the areas we had identified as being of concern. The provider sent us an action plan which detailed the actions they were taking to improve the service.

Following this inspection we were made aware of further concerns in relation to people’s safety and how risks were managed, particularly in the Reminiscence area. As a result we undertook a focused inspection to look into how the risks associated with people’s care was managed, whether people were safe and whether the home was well – led.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Sunrise Operations Knowle Limited on our website at www.cqc.org.uk

At this inspection we found that whilst some actions had been taken to drive improvement in relation to the processes to support people’s safety and manage risks, further improvements were still required in relation to the governance of the service. This meant there was a continued breach of this regulation.

A requirement of the service’s registration is that they have 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 a 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 a registered manager in post who had been registered since July 2016.

There were not always enough staff available to provide the support people required in order to meet their needs and preferences, particularly over the lunchtime period. New staff had been recruited resulting in a reduction of temporary staff being used, but at times people were still not supported effectively.

Risk assessments were completed to reflect the risks to people’s health and wellbeing; however we found some had not been reviewed regularly and were inaccurate, so we could not be sure people would be supported correctly. However, staff spoken with knew the risks to people when providing care and other care records were now being completed accurately and in a timely way following the introduction of a new system.

Continued changes within the management team had affected staff confidence and some staff told us they found the changes unsettling. Some staff told us they felt supported through meetings and supervision, however other staff did not.

Overall people, relatives and staff felt there had been some improvements at the home. More staff had been employed and less agency staff were used. There were opportunities for people and staff to raise concerns with the management team.

People and relatives told us people felt safe at the service. Medicines were administered as prescribed, and stored and disposed of safely.

People had opportunities to feedback about the service they received through surveys and meetings.

Staff were trained in safeguarding

We carried out this inspection on 7 and 24 March 2016. The inspection was unannounced.

The service is registered to provide care for up to 131 people and offers accommodation for people who require nursing or personal care. At the time of our inspection there were 114 people living at the service. The home is divided into two units, the Assisted Living area and the Reminiscence area, for people living with dementia.

A requirement of the service’s registration is that they have 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A registered manager had not been in post since October 2015.

A new manager had been in post since January 2016, and was in the process of applying for registration. We have referred to them as the ‘manager’ in the report. A temporary general manager was also employed managing the Reminiscence area of the home, and we have referred to them as the ‘general manager’ in the report.

We completed an unannounced focused inspection on 16 November 2015. This inspection was in response to concerns we received about how people’s care was managed. This included people who were at risk of falling and the management of people’s medicines. The inspection team visited the service and looked at two of the five questions we ask about services: is the service safe and is the service well-led. At this visit we identified a breach of regulation in relation to how the provider monitored and assessed the quality and safety of the service provided. Also a breach of regulation in relation to safe care and treatment of people in relation to the management of medicines, and in relation to staffing levels, and how staff were supported.

We visited this service again on 7 March 2016 following further concerns raised in relation to the management of medicines and the safety of the care provided. At this visit we found that some improvements had been made in the management of the service, however we continued to have concerns in relation to how people’s care was provided. At times, the quality and safety of care people received remained unsatisfactory and there were not always enough staff available to support people at the times required. We sent the provider a letter outlining the areas for urgent improvements. Following this, the provider sent us an action plan detailing how they would improve.

We returned to the service on 24 March 2016 to complete our inspection and also review the management of medicines. At this visit we reviewed the action plan that the provider had sent us in March 2016. We found that improvements had been made and actions had been taken in relation to most of the areas of concern. Where action had not yet been taken, the management team were able to show us plans to address the other areas of concern. Although some further improvements were still required, the provider was no longer in breach of the regulations in safe care and treatment of people, in relation to the management of medicines, and in relation to staffing levels. However, they were still in breach of the regulation in relation to how the provider monitored and assessed the quality and safety of the service provided, as these systems were not yet established.

At our visit on 7 March we had found people’s health and social care needs were not always reviewed regularly. Care records were not always completed by staff correctly. Staff told us this was because they did not always have time to do this. Risk assessments were completed, however plans did not consistently minimise the risks associated with people’s care.

Although more staff were being recruited, there was not always enough staff available to support people

We carried out an unannounced comprehensive inspection of this service on 19 January 2015. After that inspection we received concerns in relation to how the risks associated with people’s care was managed. This included people who were at risk of falling and the management of people’s medicines. As a result we undertook a focused inspection to look into how the risks associated with people’s care was managed. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Sunrise Operations Knowle Limited on our website at www.cqc.org.uk

We carried out the focussed inspection on 16 November 2015. The inspection was unannounced.

Sunrise Operations Knowle Limited is registered for a maximum of 131 people offering accommodation for people who require nursing or personal care. At the time of our inspection there were 118 people living at the service. This included people who were living with dementia.

A requirement of the service’s registration is that they have 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 a 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 in post and there had not been since October 2015, when the previous registered manager left. An interim manager had been in post for two weeks and a new manager was due to start in January 2016.

There was not always enough staff to provide the support people required in order to meet their needs and preferences.

Medicines were not always administered as prescribed, or stored and disposed of safely. There were not always protocols for medicines given ‘as required,’ so we could not be sure these were given consistently.

People and staff told us they could not always raise concerns with the management team, who were not always approachable. However, they felt more positive with the recent changes and that a new interim manager had been appointed.

People told us they felt safe living at the service. Staff were trained in safeguarding adults and understood how to protect people from abuse. Checks were carried out prior to staff starting work to minimise the risk of recruiting unsuitable staff to work with people who used the service.

Risk assessments reflected the risks to people’s health and wellbeing; however they were not always reviewed regularly.

The new management team had identified some areas that required improvement and were putting plans in place to address these areas.

Quality monitoring audits had been undertaken and these had identified some concerns, however we were not always able to see actions taken following issues being identified.

We found a number of 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.

This inspection took place on 19 January 2015 and was unannounced.

Sunrise Operations Knowle provides residential and nursing care to older people including people who were living with dementia. It is a purpose built home which is registered to provide care for 131 people. Care is provided across three floors, in two separate homes on the same site. At the time of our inspection there were 108 people living at Sunrise Operations Knowle.

At our last inspection in September 2014 we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to the care and welfare of people, the number of suitably qualified and skilled staff and medicine management. The provider sent us an action plan telling us the improvements they were going to make, which would be completed by December 2014. At this inspection we found improvements had been made.

A registered manager was 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 and associated Regulations about how the service is run.

All of the people we spoke with told us they felt well cared for and felt safe living at Sunrise Operations Knowle.

Care plans contained accurate and relevant information for staff to help them provide the individual care and treatment people required. We saw examples of care records that reflected people’s wishes. We found people received care and support from staff who had the appropriate clinical knowledge and expertise to care for people.

People told us they received their medicines when required and we found the system in place to make sure people received their medicines safely had improved. Staff who were trained to administer medicines had been assessed as competent which meant people received their medicines from suitably trained, qualified and experienced staff.

Systems and processes were in place to recruit staff that were suitable to work in the service and to protect people against risks of abuse.

People told us staff were respectful and kind towards them and staff were caring to people throughout our visit. We saw staff protected people’s privacy and dignity when they provided care to people and staff asked people for their consent, before any care was given. However, we found one example where a person’s dignity was not respected. From speaking with staff and the registered manager we were assured this was an isolated incident and not common practice.

Staff understood they needed to respect people’s choice and decisions. Assessments had been made and reviewed to determine people’s capacity to make certain decisions. Where people did not have capacity, decisions had been taken in ‘their best interest’ with the involvement of family and appropriate health care professionals.

The provider was meeting their requirements set out in the Deprivation of Liberty Safeguards (DoLS). At the time of this inspection, one application had been submitted and approved under DoLS for people’s freedoms and liberties to be restricted. The registered manager had recently contacted the local authority and referred people living in the reminiscence unit to see whether further applications required approval. The registered manager told us there were going to review people in the assisted living unit in line with recent changes to DoLS. This would ensure people’s freedoms were not restricted unnecessarily.

Regular checks were completed to identify and improve the quality of service people received. The provider completed regular checks and audits to make sure actions had been taken that led to improvements. People and relatives told us they were listened to and supported by managers or staff and if they had raised concerns, people said they had been responded to in a timely way.

This inspection was completed by four inspectors and a pharmacist. During our visit we spoke with the Deputy Manager, the Assisted Living co-ordinator, the Reminiscence co-ordinator, four nurse staff, two lead care managers, five care managers, two agency care managers and one medications technician (med tech). Lead care managers, care managers and med tech’s provide care and support to people living at Sunrise Knowle. We also spoke with three people who lived there and seven visiting relatives.

When we inspected the home there were 112 people living there. The home was laid out over three floors and occupied two separate units. One unit was called ‘Assisted Living’ for people who had some levels of independence and the other unit was called ‘Reminiscence’ for people who had varying levels of dementia related illness. Both homes provided nursing care to people.

At our previous inspection in February 2014 the provider was not meeting the regulations in relation to care and welfare and staffing. Following the inspection the provider sent us an action plan to tell us the improvements they were going to make. During this inspection we looked to see if these improvements had been made. Prior to our follow up inspection we received concerns from people and relatives of people who used the service. These concerns were around the levels of care and support people received and also concerns with medicines.

We carried out observations of care throughout the home during our inspection. The evidence we collected helped us to answer five key questions; is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, staff and visiting relatives told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

At this inspection we found improvements had been made since our last inspection however further improvements were still required. We saw care records did not contain enough information about people’s individual needs. For example, we found insufficient information and guidance was available to staff for people who displayed challenging behaviours.

We observed staffing levels during our visit. There were times when there was no visible staffing presence to assist or support people if they needed help. Some of the people we spoke with also expressed their concern over staffing levels, particularly in ‘Reminiscence’ unit.

The home had policies in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). We saw no recent DoLS applications had been submitted. The deputy manager was aware of the latest guidance and information on DoLS and was planning a review of people’s needs in light of this guidance.

People were not protected against the risks associated with medicines because the provider had not made appropriate arrangements to manage medicines safely.

Is the service effective?

We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people’s care and support needs remained appropriate. We were aware that the provider had started to review care plans, however further improvement were required. We found some care plans had not been reviewed for some time and people’s care needs had changed, but records did not reflect this. We have asked the provider to tell us how they will make improvements.

We found it was not always clear from speaking with staff that they had a good understanding of people’s care needs. We saw some care records did not contain people’s life histories or personal background information. This made it difficult for some staff to know people well enough to support them appropriately. We have asked the provider to tell us how they will make improvements.

Is the service caring?

We saw staff were attentive to people’s needs throughout our inspection; however we also saw examples were people did not receive the individual support they needed. For example, one person required support to eat and when they refused, the staff member did not provide any encouragement or further assistance.

Is the service responsive?

People were able to make choices about their day to day lives and people in ‘Assisted Living’ had access to all parts of the home. We saw couples were able to share a room which meant people had a choice in how they wanted to continue to live their own lives.

We saw people were supported to remain as independent as possible. Staff we spoke with told us how they supported people to do this.

Is the service well led?

People were able to access help and support from other health and social care professionals when necessary.

We found on some floors nursing staff and care staff did not always have a clear understanding of who was leading the shift.

We carried out a responsive inspection at Sunrise Knowle on 27 February 2014. This was because we had received concerns relating to standards of care. We looked how people were being cared for at each stage of their care and treatment. We talked with people who used the service, relatives and staff.

Three inspectors visited the service. Two inspectors visited the reminiscence unit, and one inspector visited the second floor of the assisted living service.

Sunrise Knowle had a newly appointed general manager and deputy manager.

We saw a twelve point action plan was in place highlighting areas for improvement. For example, end of life care, medicines management, and nutrition.

We observed staff interacting with people with kindness, one person told us, “Staff are excellent, I have everything I need “. We reviewed the care of six people with varying levels of need. We found care plans did not always reflect people’s needs.

We saw people were offered a range of meal choices, and their nutritional needs were met.

The service acted appropriately to reduce the risk of harm to most people, however we saw people were not always protected against the risk of pressure ulcer development.

We saw staff had attended mandatory training, however there was poor uptake on specialist training and staffing levels did not ensure care was delivered in a timely way.

Improvements were being made at Sunrise Knowle but significant further work was still needed.

At the last inspection in April 2013 we found the provider to be non compliant in the outcome area of record keeping. This visit was carried out to check that the provider had implemented their action plan and changes had been made to the care documentation and general record keeping.

We visited the home in August 2013 and spoke at length with the Deputy Manager about the changes that had taken place. We also looked at a number of records including care plans, risk assessments and staff training documents.

We found care documentation files were much more organised. Out of date paperwork had been archived from the files. Records of staff training reflected the actual training staff had undertaken or were due to complete.

Regular staff meetings were being held to discuss aspects of care practice including record keeping and reporting. The minutes of which were documented and referred to as necessary.

The providers action plan had been fully implemented, and we found the service to be compliant.

On the day of our inspection there were 118 people living at the home. There were four nurses and thirty four care staff on duty. Along with the general manager and two care managers, a housekeeping team and catering staff were also working in the home. Other staff on duty included activity workers, administration staff and a concierge in each unit to greet visitors as they arrived.

The atmosphere in the home was welcoming. Staff were professional and friendly, people living there were settled and engaged in conversations and activities, and visitors to the home were made very welcome.

We spoke with eleven people living at the home, fourteen members of staff and two relatives who were visiting at the time of our inspection.

Staff had received training in dementia care and this was evident from the interaction we observed. Staff now took the time to sit with individuals and offer choice and options, not just decide what was best for them.

Recruitment was much improved. A number of staff had been appointed to fill the outstanding vacancies. The manager was confident that within six weeks the home would be fully staffed by permanent staff and there would be no need to use agency staff. People living at the home told us there were less agency staff being used and they liked having staff who knew them well.

We visited the home as we had received information of concern from a number of sources. The home had suffered from previous poor management and a number of processes had not been followed resulting in people living at the home receiving an unacceptable standard of care.

The provider had recognised this and had brought in an experienced management team, six weeks prior to our visit. During the short time the management team had been in place they had made a great number of changes throughout the home. Detailed action plans were in place for all areas of the service and we could see evidence of improvement during our visit.

The home remains non-compliant. Although plans were in place to improve the service there was still a lot of work needed before the home could be classed as compliant.

Sunrise Knowle consists of two separate buildings on the same site. One for general residential and nursing care, and the other for dementia residential and nursing care. During our visit we spent time in both buildings and spoke to staff and people living at the home.

People living in the general carehome told us staff were hard working, kind and very helpful. We were unable to get any comments from people living in the dementia carehome due to the nature of their illness.

Staff told us morale had been low amongst the staff team. They felt that with the new management team in place things were slowly improving. They felt able to talk to the managers and express their views.