Birch Avenue

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The service's vision, strategy and culture, needed embedding into practice, including how staff understood their roles to implement these effectively. Work was ongoing to address this, through a new and strengthened leadership team, with new systems and processes being implemented. For example, through supervisions, team meetings and role modelling. This was to ensure all staff demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service.

Not all leaders understood the context in which the service delivered care, treatment and support. The manager was in the process of registering with the Care Quality Commission. Previous changes in management had affected leadership stability and impacted on quality and continuity of care within the service. However, staff spoke positively about the new manager with a staff member telling us, “We had no direction before [manager] came, we had no leadership and it was a very concerning time. However, since [manager] has come, I can really see a difference in the service and how it is being run. We have more structure to our days and if things aren't done, we are pulled up on it. It's much better with the new systems." Although new processes were being implemented by the new manager, we found the managers knowledge around some areas of governance, such as having oversight of audits and identifying gaps in care provision required improvement; to ensure they were aware of their legal responsibility for the day-to-day operation of a regulated care service, ensuring compliance with CQC standards of safety, effectiveness and care quality.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff understood whistleblowing procedures and told us they felt confident bringing areas of concern to leaders’ attention. A staff member told us, “I think we have an open culture here. We have a 'speaking up' person who comes into the service on a regular basis, who we can talk openly with if we have any concerns. I feel able to raise any issues and feel [manager] would act on them straight away."

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The service employed a diverse staff team including staff from different ethnic backgrounds and genders. Staff meetings and supervisions showed staff were included in decision making. Staff spoke of an inclusive culture where there was support for each other. Workforce wellbeing schemes and reasonable adjustments were available to employees if these were required.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Audits and governance procedures were not effective and did not identify the shortfalls we found during our assessment. The systems failed to ensure that care matched people’s assessed needs or that records accurately reflected their experiences. The systems and processes in place were not always accurate, complete or contemporaneous. We found examples where people’s care records were insufficiently detailed, did not accurately reflect people’s experiences and did not contain sufficient information for staff to manage people’s specific needs or conditions. Risk assessments had not always been completed for known risks and mitigation plans were not always in place as per people’s assessed need. There was a lack of oversight and knowledge from leaders at all levels within the service around roles, responsibilities and accountability to enable good governance. Leaders within Birch Avenue were reflective that certain areas of governance, such as the environment, had been impacted by in-effective communication between the service and provider and that certain processes required streamlining to ensure effective care, treatment and support for people going forwards. The service was working with the local authority to improve areas of care provision and as a result, have implemented some new systems and processes. However, these systems, and the further improvements required needed to be embedded and sustained, and the provider needed to ensure effective oversight at all levels within the service going forwards.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Professionals were positive about the service’s ability respond in a timely manner and that staff were knowledgeable about people’s needs during their visits to the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Monitoring systems were not effective and had not identified some of the issues we found during the assessment, as detailed in the various sections of this report. We found learning following incidents was not always well documented, and gaps in audits around people’s care records had been outstanding for a considerable length of time. Further work was needed to establish a consistent culture of learning, innovation and improvement. The service were committed to delivering a quality service and responded promptly to shortfalls identified during the assessment.