This inspection took place on 4 January 2016 and was unannounced .

Silver Birches provides residential care for up to 50 people, some of whom have dementia or physical disabilities. The bedrooms are located on the ground and the first floor. The service is split into three units: Robin, Jay and Kingfisher. Kingfisher unit supports people with advanced dementia who have a high level of care needs. At the time of our inspection there were 49 people using the service.

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 2008 and associated Regulations about how the service is run.

People told us their care and support needs were met by staff who were knowledgeable and knew them well. Staff had undertaken training relevant to the specific needs of people who lived at the home and staff told us they were supported within their job roles.

Everyone we spoke with said they thought Silver Birches was a safe place to live and that they were well cared for. Staff had a good understanding of how to report any concerns of a safeguarding nature. Overall, staff had a good understanding of how to keep people safe. However, we found one occasion when poor communication between the staff team had resulted in the risk associated with a person’s care not being well managed.

Staff were not always available at the times people needed them. The registered manager told us actions were being taken to address this. A dependency tool was used to assess the number of staff needed. The number of care staff on each shift had recently been increased during busy periods there were not always enough staff to respond to people’s needs without delay. The registered manager told us further actions were being taken to address this.

People received their medicines as prescribed and checks were undertaken to ensure they received them in a safe way.

Mental capacity assessments were completed when needed and specified the nature of the decision the person was being asked to make. This demonstrated that the provider was following the principles of the Mental Capacity Act (2005). When people had a DoLS authorisation in place for continuous monitoring, it was reviewed within the specified time frame to ensure that people were not being deprived of their liberty unlawfully.

Most staff ensured they maintained people’s privacy and dignity and treated people with compassion and respect. However, we observed two occasions where this was not the case.

Health and safety risk assessments had been completed. Specific risk assessments had been completed for moving and handling and falls whilst other risks and interventions were assessed using the care plan documentation. Any incidents were logged and an analysis of accidents and incidents was completed so staff could identify any trends and manage them accordingly.

There were robust recruitment procedures in place which included checking people’s full employment history, references and a DBS check. This reduced the risk of unsuitable staff being employed by the service.

People’s nutritional and hydration needs were being met. People had a choice of meals which met their dietary requirements and preferences. People were supported to maintain their health.

People had opportunities to pursue their hobbies and interests and maintain relationships with people important to them.

People and their relatives knew how to raise complaints and were confident actions would be taken in response to these. People had opportunities to put forward their suggestions about the service provided.

There were processes to monitor the quality and safety of the service provided and actions were taken to drive improvement in the service.

This inspection was completed by two inspectors and an expert by experience. During our visit we spoke with the registered manager, six care staff, an activities co-ordinator, a cook, and a housekeeper.

We found there were 40 people living at the home at the time of our inspection. We were able to speak with 11 people and two visiting relatives about their experiences of the care and support they received at Silver Birches.

We carried out observations of care throughout the home. 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?

People were cared for in an environment that was maintained and suitable for the needs of the people.

People and relatives told us they felt they and their relatives were well looked after. We were told: “If you want them to help, they help you”, “You can do what you like, have a shower when you like. Have a bath when you like” and, “I don’t find anything I don’t like.”

We found staffing levels at the home met the needs of the people. The registered manager told us they had recently increased staffing numbers by one care staff member on each unit. Staff we spoke with told us this increase in staffing had helped. One staff member said: “We can spend time with people more.”

We spoke with staff who told us they had not read or accessed people’s care records on a regular basis. This had the potential to place people at risk of receiving inappropriate care and support. Staff we spoke with raised concerns with us about the numbers of agency staff available. Staff told us agency staff shadowed other care staff but only read one or two care plans before they provided care to people because they did not have sufficient time to read more.

The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom. We spoke with the registered manager about the recent judgement by the Supreme Court in relation to (DoLS). They told us they had taken appropriate advice to ensure they complied with any changes in the local authority's policy and procedures. The registered manager told us they were considering making applications to the local authority for a number of people who used the service where the judgement potentially impacted on their rights to freedom.

Is the service effective?

People and relatives we spoke with told us they were happy with the care provided. One person told us that when they rang their call bell, staff came: “Within 3 minutes. They are very good like that."

We found some of the care records we looked at did not reflect people's current needs. These care records did not contain any risk assessments or have the appropriate guidance for staff to follow to ensure they did not place people at risk of receiving inappropriate care.

We saw care records had been reviewed, however these reviews did not support people’s current or changing care needs. The registered manager acknowledged these concerns and agreed to make improvements to the records.

We have asked the provider to provide us with information as to how they will ensure care plans support people’s individual care needs.

Is the service caring?

People were supported by staff who were kind and attentive. We saw and heard people given choices throughout the day about where and what they wanted to eat or drink, where they wanted to sit and what they wanted to do. We saw staff spent some time with people on a one to one basis. We also saw staff spent time with people and cared for people at their preferred pace.

Some staff we spoke with told us they felt they were not always able to provide the care they wanted because they did not have time to read people’s care records. One staff member told us: “When you’re providing care, you just don’t get time and we have a lot of agency staff.” This staff member also said: “Most staff have learnt from residents and each other.” Another staff member told us: “Staff aren’t updating the professional visits logs which they should do.”

Is the service responsive?

People were supported to participate in activities inside and outside of the home. At the time of our inspection people played skittles in the lounge area. We also saw one person who smoked, sat in the garden area. This person said: “I am always in the shelter, I like it here.”

Is the service well led?

The service did not have an effective system in place that assured them of the quality of service they provided. The service completed some checks and sought the views of people who used the service. However, there was little evidence to demonstrate what actions had been taken that led to improvements.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people receive a quality of service.

During our previous visit on 29 April 2013 we found improvements were needed to medicine management. This resulted in us issuing a compliance action. We found some care staff had not completed the administration records sufficiently to demonstrate topical medicines (e.g. prescribed creams) were administered as prescribed. Additionally, some people had not been receiving inhaled medicines as prescribed. We found a number of people had been prescribed medicines which were to be taken on a ‘when required’ basis. We saw care plans did not have enough information in them about how staff should handle and administer these medicines.

We also discovered systems were not in place to ensure the safe administration of controlled drugs. There was also a problem with the first floor medicines fridge which meant a medicine was not stored within the correct temperature range.

During our latest visit on 5 August 2013, we found our concerns had been addressed. We saw evidence that the medicines management procedure had been improved and appropriate action taken to correct our areas of concern. We spoke with a senior carer, who was the officer in charge, two care workers and four people who used the service. One staff member said, “The medicines procedures are much clearer now.” People we spoke with said they received their medicines when they needed them. One person said, “They are very regular and I always get a smile.”

During our last visit we found improvements were needed to medicine management. This resulted in us issuing a compliance action. Medicine records had not been signed by staff and people had not received their oral medications as prescribed. During this visit we found some improvements had been made in these areas. We found further actions were required before the service would be fully compliant.

We spent time sitting with people in the three lounges known as Kingfisher, Jay and Robin. This was so we could observe how people were being cared for. These observations were used alongside other information gathered to assess the quality of care and support. We saw there was a calm and relaxed atmosphere in the home.

People we spoke with and visitors were positive in their comments. One person said, “The staff are friendly and there’s a good atmosphere.” A relative of a person who lived at the home told us the home is, “Absolutely wonderful. They have made her (mother) feel so at home.”

People looked clean and tidy. We saw staff supported people to maintain their independence. For example, we saw one person helped to dry cups in the kitchen. At lunch time we saw people enjoying their meals. Some people commented the food was “excellent”. Those who needed assistance were supported by staff. We observed staff were respectful towards people and interacted with a pace and level appropriate for people’s needs. One person said, “I’m very happy since I’ve been here.”

During our last visit we found improvements were needed to medicine management. This resulted in us issuing a compliance action. Medicines available did not correspond with records which meant we could not be confident people had received their medicines as prescribed. There were also concerns medicines were being stored at temperatures that were too high for them to retain their effectiveness.

During this visit we found some progress had been made to address the improvements needed for effective medicine management within the home. We found further actions were required before the service would be fully compliant.

During our last visit we also identified improvements were needed in relation to the staffing arrangements. This also resulted in a compliance action being issued.

During this visit we found sufficient improvements had been made for the service to be compliant. We observed that staff were not rushing to carry out their duties as they were previously. We saw volunteers were helping out on the units. We saw evidence that staffing arrangements were being reviewed. This included plans to closely monitor changes in people’s needs to identify where any staff increases may be needed.

We spent time sitting with people in each of the three lounges known as “Jay”, “Robin” and “Kingfisher”. This was so we could observe how people were being cared for. These observations were used alongside other information gathered to assess the quality of care and support being provided. We found that there had been improvements made since our last inspection in relation to the care and protection of people.

We saw that most of the time there was a calm and relaxed atmosphere across the home. The exception was when music was being played when we saw people smiling, alert, singing and tapping feet and fingers to familiar tunes.

People that we were able to speak with and visitors were positive in their comments about the service. Visitors told us that they were kept informed about their relative. One visitor told us: “They keep me informed on the phone straight away if there are any problems.” “It’s great here, mother loves it.”

People looked clean with their personal care needs met and we saw that staff supported people to maintain their independence. This included a person having their own key to their room so they could lock it when they wished.

At lunch time we saw people enjoying their meals. Some commented that the food was “good”. Those that needed assistance were being supported by staff.

We observed that staff were respectful towards people. Some had a more interactive approach with people than others. Visitors were complimentary of the staff. They told us: “staff good, polite”. “Staff do really well, a good place”.

When we were sitting in the Jay lounge we saw that the staff were rushed with little time to spend with people due to their workloads. We found that staffing arrangements did not always support the level of need that some people required to keep them safe.

We found that some improvements were needed in relation to medicine management. This included the storage, administering and recording of medicines.

Many of the people living in the home were not able to tell us about their experiences due to their dementia. We spoke with five people who told us they liked living in the home and were well looked after. One person said “The girls are good”.

Another person said “I find it good. Get a drink. Legs treated by district nurse.”

People generally felt well cared for.

Most people we spoke with said they enjoyed the food. One person said “The food is so-so”. People we spoke with told us they had not been asked about what they wanted earlier in the day. They did not know what they were going to eat for lunch that day. They told us that there were two choices each day. They told us they were asked what they wanted at mealtimes.

We watched how care workers spoke to people during the day and how they were offered choices at lunchtime. We saw that people were responded to quickly and in a kind way. We saw that people were offered choices such as the food they ate and where they sat.

People were not always safeguarded. Some incidents had been raised at the home in respect of incidents including theft and some poor care practices at the home.

Relatives told us:

"Happy with the home, lovely people."

"Its fantastic. She gets everything she needs - food and company"

"Don't need to worry about them. They're on the phone straight away to tell you if something's wrong. They are goods as gold."

"Had a fab Christmas, his general welfare has improved since moving into the home. Staff always prepared to answer questions. One thing to improve could give relative more information for example about you people and how to contact you."

People living in the home told us:

"Food is ok. Like stews. Get them 2 or 3 times a week. Don't often get a lie in. Can on Sunday"

"Food is lovely. Been here 7 years."

"Happy , no complaints. Can see doctor when needed. Food is ok. They make the small chips I like big fat ones."

"Well looked after. It’s a pleasure to be here."

"We have someone to put us to bed."

"Staff very good."

"Smashing home, good staff nice manager."

"Staff ok, home ok, like bedroom. Good meals."

"My family had decorated and furnish bedroom lovely"

"Staff alright. They really look after you. Having chiropodist in to day. They have

improved at one time two residents used to come in my room, but now they don’t

now which is good so they have improved that. Bedroom nice every thing is nice

here. I like the home and staff"

"The dinning tables should be split up so you can get in and out of the chair. Had fish today very nice. Can ask for anything really."

"Don’t know about care plan to ask the staff.

"Asked about female and male carers, makes no difference to."

"Staff not too bad’’

“Don’t know about care plan’’

“Do most things myself. Staff treat me ok. Home alright. Staff knock door and ask what I want’’

Comments from quality assurance feedback forms :

Personal care - very good.

Medication - no mistakes yet, and I think I get it on time.

Activities - especially like the bingo, activity is important and I like to take part when I can.

Laundry - not always getting clothes back on time.

Staff - Staff are very helpful and very good.

Visitors - I like to have visitors when I want them.