This inspection took place on 9, 10 and 17 October 2018 and was unannounced. This meant the provider and staff did not know we would be attending.

The service was last inspected in January 2017 and was rated Good. When we returned for this latest inspection we found that medicines were not managed safely. We also found issues with staffing levels, training and governance and management processes. As a result, the rating of the service changed to requires improvement.

This is the second time the service has been rated requires improvement. It was last rated requires improvement at an inspection in 2016.

Briarwood Care Home 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. Briarwood Care Home accommodates up to 49 people across two units. One unit provides general nursing and residential care, and one unit provides nursing and residential care for people living with a dementia. At the time of our inspection 44 people were using the service.

The service had a manager, who joined the service in June 2018 and had applied to be registered manager 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. They will be referred to as the manager in this report.

The provider, Premier Nursing Homes Limited was taken over by Hill Care Limited in March 2018. Hill Care Limited retained the name and legal status of Premier Nursing Homes Limited as the provider of this service, but replaced them as the legal owner.

Medicines were not always managed safely. Staffing levels were not always sufficient on the unit for people living with a dementia. Staff at the service had not always received the training deemed mandatory by the provider. The provider’s governance processes were not always effective at identifying and resolving issues.

The provider’s recruitment processes minimised the risk of unsuitable staff being employed.

Risks to people were assessed and plans put in place to reduce the chances of these occurring. The premises were clean and tidy and the provider had effective infection control systems. Plans were in place to support people in emergency situations. People were safeguarded from abuse.

Staff were supported with regular supervisions, and appraisals were planned. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. The service worked closely with a wide range of external professionals to ensure people received the healthcare they needed. People were supported to manage their food and nutrition. The premises were adapted for the comfort and convenience of people living there.

People spoke positively about staff at the service, describing them as kind and caring. Throughout the inspection we saw numerous examples of staff delivering kind and caring support. People were treated with dignity and respect and were supported to be as independent as possible. Policies and procedures were in place to support people to access advocacy services.

Care plans were in place based on people’s assessed support needs and preferences. People were supported to access activities they enjoyed. Policies and procedures were in place to investigate and respond to complaints. Nobody at the service was receiving end of life care at the time we inspected, but policies and procedures were in place to support people.

Staff spoke positively about the manager and the change of leadership at the servi

This inspection took place on 13 and 25 October 2016. The first day of the inspection was unannounced which meant the registered provider and staff did not know we would be visiting. The second day of inspection was announced.

At the last unannounced, comprehensive inspection on 15 December 2015, we identified short falls in staff training and medicine management. There was a lack of recruitment checks for agency staff and best interest decisions were not being made when people lacked capacity. The premises were not clear and there was a malodour throughout and some furniture was in need of replacement. We asked the provider to take action to make improvements to ensure they were meeting regulations. At this inspection we found that the registered provider had taken appropriate action and the service was no longer in breach of any regulation.

Briarwood provides nursing and residential care for up to 49 people and is a purpose built home with a residential unit downstairs and a nursing unit upstairs. The service predominantly supports older people with dementia care needs. The service provides lounge areas, dining areas and bathing facilities. All rooms at the service are en-suite. The service is located close to local amenities and bus routes.

There was a manager in place, who had started the process of applying to be the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives told us they felt safe. Risk assessments were in place for people who needed these and they had been regularly reviewed and updated when required.

Accidents and incidents were monitored to identify any patterns and appropriate actions were taken to reduce the risks. Falls were also monitored to identify if any trends were occurring.

Staff we spoke with understood the procedure they needed to follow if they suspected abuse might be taking place and the provider had a policy in place to minimise the risk of abuse occurring. Safeguarding alerts had been made and recorded when needed.

Emergency procedures were in place for staff to follow and personal emergency evacuation plans (PEEPS) were in place for everyone. PEEPs provide staff and emergency services with information about how they can ensure an individual’s safe evacuation from the premises in the event of an emergency. A robust procedure for recording fire drills had been implemented.

Medicines were stored and managed appropriately. The provider had policies and procedures in place to ensure that medicines were handled safely. Medication administration records were completed fully to show when medicines had been administered and disposed of. People we spoke with confirmed they received their medicines when they needed them.

Certificates were in place to ensure the safety of the service in areas such as electrical testing, controlled waste, legionella and fire fighting equipment. Regular checks were made by the maintenance staff in areas such as water temperature, emergency lighting and fire alarms.

A safe recruitment process was followed to reduce the risk of unsuitable staff being employed. All new staff completed a thorough induction process with the registered provider.

There was sufficient staff on duty to meet the needs of people who used the service and people and relative we spoke with confirmed this. Call bells were answered in a timely manner and staff were visible throughout the service.

Staff performance was monitored and recorded through a regular system of supervisions and appraisal. Staff had received training to support them to carry out their roles safely.

People were supported to maintain their health. People spoke positively about the nutriti

We inspected Briarwood Care Home on 15 and 18 December 2015 and 6 January 2016. The inspection on the15 December 2015 was unannounced which meant that the staff and registered provider did not know that we would be visiting. We informed the registered provider we would be visiting on 18 December 2015 and 6 January 2016.

Briarwood is a purpose built care home which provides residential and nursing care for up to 49 people. At the time of the inspection 40 people were living at the service. The service provides residential care on the ground floor, nursing care on the first floor and the second floor of the premises accommodates the kitchen, laundry and office facilities.

Briarwood supports people living with dementia. The service had four beds which were funded to support people who are experiencing acute difficulties with confusion and needed support when leaving hospital before they go home or whilst assessments can be completed.

The home did not have a registered manager in place. 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 time of the inspection a manager was in post and had been since 25 June 2015, they confirmed at the inspection they had commenced their application to become the registered manager.

The communal environment in the service was poor as it had a bad odour, plus the flooring and seating was badly stained and in need of replacement. The manager had already recognised this and was working with the registered provider to organise replacements.

We found that safe recruitment and selection procedures were not always followed to ensure appropriate checks had been undertaken before staff began work. Gaps in employment history were not always explored and where agency staff were used to cover shifts we found the manager was not obtaining robust information on the staff the agency was providing.

People told us that there was enough staff on duty to meet people’s needs. The records we saw and observations we made confirmed this.

We found that medicines were not administered safely. We looked at all the records relating to the management of risk and incidences. We found improvements were needed around the risks associated with fire.

We saw that records where staff recorded accidents and incidences did not reflect any learning to prevent future reoccurrence.

Staff who worked at the service had not received appropriate levels of training to enable them to carry out their duties effectively.

Although staff we spoke to told us they felt supported, records showed that staff had not received enough supervision from their line manager or an annual appraisal.

We found that the service was not using the Mental Capacity Act (MCA) to support people who may lack the capacity to make their own decisions to receive support that was deemed in their best interests. Staff had basic knowledge of the MCA and were observed to be working in a way that empowered people to make their own choices and delivering support how people liked to be supported.

The service could not provide us with the number of people who were authorised to be deprived of their liberty at the time of the inspection. Due to the system being unorganised could lead to people being deprived of their liberty unlawfully.

The registered provider had a system in place for responding to people’s concerns and complaints. But this was not always adhered to. People regularly had opportunity to voice their views. There were no effective systems in place to monitor and improve the quality of the service provided.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. Although people w

The inspection team consisted of one inspector. During the inspection, we spoke with six people out of 48 people living at Briarwood, the manager, deputy manager and three care staff. We looked at seven sets of care records. We also observed care practices within the home.

The management of the home was good and we saw strong leadership in place and a positive environment for people and staff. Staff spoke highly of their manager and the support which they received.

We set out to answer our five 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. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Everyone we spoke with told us they felt safe and secure living at the home. Staff we spoke with understood the procedures which they needed to follow to ensure that people were safe. The manager

Care plans and risk assessments were in place and updated on a regular basis and were based on people’s individual needs and preferences.

Systems were in place to make sure that the manager and staff learnt from events such as accidents and incidents, concerns, complaints, whistleblowing and investigations. This helped to reduce the risk of harm and ensured that lessons were learnt from mistakes and any issues highlighted and addressed.

Is the service effective?

Everyone had their needs assessed and had individual care records which set out their care needs.

It was clear from our observations and from speaking with staff that they had a good understanding of the care and support needs of people living at the home and that they knew people well. Assessments included dietary, social and leisure and emotional needs.

One person spoke highly of the staff and said that they were happy with the care that had been delivered and their needs had been met.

People had access to a range of health care professionals and all relevant information was documented in the care files.

Is the service caring?

People were supported by kind and attentive staff who showed patience and gave encouragement when supporting people, whilst helping them to remain independent.

People who used the service, their relatives and friends were asked for their views on the care and service provided. Where shortfalls or concerns were raised, however small, these were taken on board and dealt with. The manager maintained on-going communication with relatives who lived some distance away from the home via email.

One person told us; “I can relax here.”

Is the service responsive?

There was clear evidence contained within people's care plans to show how they worked with other health and social care professionals.

People told us that they knew how to make a complaint if they needed to.

Discussion with the manager during the inspection confirmed that any concerns or complaints were taken seriously. We looked at the complaints record which confirmed that complaints had been investigated thoroughly and in line with the complaints policy.

Is the service well-led?

There were systems in place to assure the quality of the service provided. The way the service was run was regularly reviewed. Actions were put in place when needed and we were able to see that these actions had been addressed.

Staff were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and were knowledgeable about people's needs. This helped to ensure that people received a good quality service at all times.

What people said:

People who were able to express their views told us; “The girls are all nice” and “I can relax here”. We saw lots of patient and caring interaction with people who were not able to communicate well. Staff told us they felt able to raise any issue with their manager and that they worked well as a team. One staff member said; “I love it here, I love the people I look after” and another told us; “We are able to air our views and things get discussed and changed if they are not working”.

At the last inspection we found that the provider had not acted in accordance with the legal requirements around making decisions on behalf of people who used the service and were limiting activities people were able to undertake independently. Where people lacked capacity to consent, the provider had not acted in accordance with legal requirements.

We found that staff presumed people lacked capacity to make choices for themselves.

We found that staff did not understand the actions they needed to take to assess someone’s capacity.

Records did not contain an assessment of a person’s capacity to make decisions for themselves and staff had not acted appropriately when people had been placing themselves at risk.

At this inspection we went back to check the action staff had taken to ensure that people were asked for their consent before any care or treatment was given. We also checked that where people didn’t have the capacity to consent, that the provider acted in accordance with legal requirements. We looked at six of 40 (15%) of the care records.

Many of the people who lived at the home found it difficult to think about recent events or at times, to have a conversation. During the visit we used a specific way of observing care to help to understand their experience of the service. We found that the nursing and care staff were respectful towards people and treated people with empathy and compassion.

During the visit, we spoke with six people who used the service. People told us that they always found the staff to be really kind and helpful. They said, “They are a lovely set of staff and so kind”, “The girls are good to me”, and “I like living here, there’s always people around to give me hand.”

We found that staff were not always able to meet people’s personal care needs, particularly if they displayed challenging behaviour. Also the records failed to show that staff had taken appropriate steps to follow the advice of visiting healthcare professionals. Neither had they alerted CQC to incidents that were occurring in the home.

We talked with six staff who were on duty about people's ability to make decisions. We found that staff were unaware of positive risk taking practices or requirements of the Mental Capacity Act 2005. Staff had been made aware that they needed to complete Deprivation of Liberty Safeguard authorisations (DoLs) for some of the people who used the service but had not completed these applications.

We spoke with one relative during our inspection. She told us that the staff and the manager were very supportive and always listened to any concerns she had. She also told us that she was always kept up to date with the condition of her relative. She said “It’s brill, staff are nice and mum seems fine”. She also thought that there were enough staff around and that they seemed to know what they were doing and were very good at maintaining people’s dignity. She added “It’s always clean here and there are never any awful smells. It’s one of the reasons we chose this place for mum.”

Because many of the people who live at Briarwood had problems with short term memory loss or had dementia, they often found it difficult to remember recent events or to hold conversations related to their care at Briarwood. We used a formal way to observe people’s experiences of living in the home and their interactions with each other and with staff. We call this the Short Observational Framework for Inspection (SOFI). We also spent time observing activity within Briarwood where we did not use the formal structure of SOFI. Both of these methods allowed us to understand better the experiences of people who lived at Briarwood.

Throughout our observations we saw people being treated with dignity and respect. We saw that staff were able to communicate with people who used verbal and non verbal communication. Staff smiled at people and asked them how they were. They also waited for people to respond and then acted according to the response.

We observed staff during meal time in one of the lounges, assisting people who didn’t wish to go to the dining room. We saw that people were given choices with food and drinks. We also saw that staff noted when people hadn’t eaten much of the meal they had chosen and offered alternatives such as sandwiches and desserts.

In addition, we saw that some people needed assistance with their food. We saw one member of staff who sat and took time to engage with the person they were helping. They encouraged the person and made eye contact often. Both they and the person they were assisting were focussed on each other and the food. This was positive and showed that the members of staff knew how to engage with the people they were assisting and made sure that they had good experiences.

The visit took place because we were following up issues raised at the last inspection in

September 2011. Therefore when talking with people we concentrated on the specific issues raised during that inspection. We spoke with nine people who used the service and three relatives as well as observing care practices. People were complimentary about the staff on both units and the current manager. They told us that the previous manager had left the home and found that the new manager was very competent and extremely approachable. People said ''This is a very good service'', ''The home is excellent and the staff are extremely kind'' and ''I have no complaints at all''. Relatives told us about the recent employment of an activities coordinator and how she was always making sure there were plenty of things for people to do. They were very impressed with the range of activities now being provided across both the units.

A proportion of the people living at the home had marked problems with their memory and found it difficult to think about recent events or at times to hold a conversation. Therefore we used a specific way of observing care to help to understand the experience of people who could not talk with us. This involved spending a substantial part of the visit observing a group of people to see how they occupied their time, appeared to feel and how staff engaged with them. We observed staff constantly working in ways that supported the people, they used information from people's life history to assist work with people and made sure individuals could follow what was being said. Both the staff on nursing and residential units approached people in a gentle and caring manner. However, on the nursing unit the staff had adopted the practice of locking one of the toilet doors, which meant people could only independently use one toilet. The area manager was made aware of this practice and undertook to ensure the toilet door handles were changed so they could only be locked from the inside.

One person said there wasn't anything happening in the home. A relative said that the carers were good and the care was alright. A relative told us that the food was not very good. One person who used the service said that she couldn't have a cigarette when she wanted one.

A relative thought that there was some "coming and going of staff" and said that there had been four new staff in the home in one week.

During this inspection we spoke with four people who used the service and four relatives. We also spoke with the manager, the area manager and five members of staff.

People told us that they were happy with the care and service received. Two relatives we spoke with told us that the care given was good and their family member was settled and comfortable. One relative said, "I visit regularly and I am always made welcome. Staff keep me up to date with how my mother has been." Another relative told us that their family member was always clean and tidy when they visited and there was a good atmosphere.

One person we spoke with told us, "I am very happy with the care here and the staff always treat me respectfully." Another person told us, "I like it here, I have no regrets about the move and the staff are very helpful." A relative we spoke with told us, "Staff always contact me if there are any changes in my mother's condition."

We saw that staff treated people with dignity and respect. Staff were attentive and interacted well with people. They provided reassurance when one person was restless and disorientated. We saw that staff communicated well with people and explanations of care were given in a way that could be easily understood.

We saw that equipment was suitable for people who needed it.

The manager took steps to ensure the quality of the service.

We saw that records were accurate and kept up to date. Records were stored safely and securely.