Birnbeck House - Care Home Learning Disabilities

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We found improvements were needed to ensure staff were effectively assessing and mitigating risks for people and ensuring staff were appropriately trained in supporting autistic people and people with a learning disability. The service was in breach of legal regulations in relation to safe care and treatment and staffing.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service was now recording and reporting safeguarding concerns. The service kept a log of safeguarding concerns and reviewed them to ensure lessons were learned.

Staff told us they were trained in safeguarding, were confident to raise any concerns, and learning was shared with them. Comments included, “I know how to escalate concerns if I need to” and “Learning is fed back to staff, we have flash meetings we talk about things that have happened.”

The service had completed mental capacity assessments (MCAs) and best interest decisions for people. Some assessments and decisions made provided clear information, were decision specific and up to date. Other assessments assessed multiple areas instead of being specific and the decision which had been made was not clear. Where people lacked capacity, assessments recorded how relevant people had been involved in the decision-making process. We saw people’s MCAs and best interest decisions were in the process of being reviewed. We fed our findings back to the provider to address as part of their review.

Deprivation of Liberty Safeguards (DoLS) referrals had been made for people where restrictions were in place and the service had a tracker to monitor the referrals.

People’s relatives told us they felt people were safe and they did not have any concerns about their relative’s care.

Adult social care professionals also felt people were safe. Their comments included, “I did not see anything that led me to raise any concerns” and “I haven’t observed anything of concern.”

However, service leaders had not recorded on the safeguarding concerns log how any learning had been shared with staff. We fed this back to the provider to address.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service had implemented an audit to assess people’s risk of choking. The audit stated agency staff who worked at the service should not support people on modified diets to eat until they had completed a dysphagia competency assessment. However, we observed an agency staff member who had not completed this assessment support a person on a level 4 modified diet to eat their lunch. Delegation sheets which the service used to plan which staff members supported people each day also showed agency staff who had not completed this assessment were allocated to support people on modified diets. Staff were not able to tell us which agency staff had completed the service’s dysphagia competency assessment. We asked the provider for an accurate list of which agency staff had completed this assessment but they were unable to provide this. This placed people at an increased risk of choking.

Staff were now recording people’s incidents of distress but these were not routinely monitored by the management team for themes and trends. The interim manager had completed some analysis of a person’s incidents of distress to gather information for a referral for external positive behavioural support. However, this analysis did not record information which may be important to support the referral, for example, days and times, and the names of staff supporting the person. Identifying themes and trends is important as it could assist in identifying ways to reduce distress for the person.

We were not assured staff were always following measures identified to reduce risks in people’s care and treatment. For example, 1 person had been assessed as being at a risk of falls and a physiotherapy referral had recommended they did not walk up and downstairs independently. While their risk assessments detailed this, the interim manager told us the person had been regularly walking up and down the stairs since the service’s stair lift had been out of order for a period of time earlier in 2025. The provider had ensured the lift was mended and implemented measures to reduce the risk to the person of falling, this included for them to be supported by staff when mobilising. However, the person had recently fallen down the stairs resulting in an injury, the person was not being directly supported by staff at the time of the fall. The person’s risk assessments did not contain information to assess the risk of them using the stairs independently.

However, people who were assessed by speech and language therapists (SALT) as being at high risk of choking had specific eating and drinking care plans which detailed any modified diets they had.

People’s care plans now had information for staff to support people to manage risks where required, this included for bed and floor sensors, personal care and skin integrity.

Staff had now completed introduction to behaviour support awareness training and 10 staff had completed external positive behaviour support training. The interim manager advised they planned to book other staff onto this training.

Staff told us risk assessments contained the information they needed, and they understood their role to keep people safe. Staff told us, “We have a duty to keep people safe and free from harm” and risk assessments were, “All documented in the care plan."

Relatives generally thought risks to people were well managed.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support and development. They did not always work together well to provide safe care that met people’s individual needs.

The training matrix and training overview spreadsheets provided were not an accurate and an effective way of monitoring training compliance. We could not be assured staff were safely trained to support people as staff names varied on each form provided. We found 3 out of 21 care staff were not trained in learning disabilities and autism tier 2. The provider was in the process of changing over to a new system to record staff training compliance. This made it difficult to review if staff were trained in line with legal requirements. We fed this back to the provider, who informed us they were already aware and had set a requirement for their training records to be up to date by the end of August 2025.

Training records we viewed did not demonstrate staff had always been adequately trained to support autistic people and people with a learning disability. The Care Quality Commission (CQC) had identified this during our last inspection in June 2024. However, records we reviewed showed 2 staff who had worked at the service for over a year had still not received this training. This was despite all people living at Birnbeck House being people with a learning disability and autistic people.

Staff competencies were checked in various areas such as dysphagia and moving and handling. The service had also introduced support observations for staff which covered if people were being supported with dignity and respect.

Staffing levels were provided in line with the service’s dependency tool. However, they did fall below this level at times when staff sickness occurred. Agency staff regularly worked at the home to cover shortfalls in staffing, this included covering the day and night shifts. The interim manager told us they aimed for regular agency staff to work at the service to minimise the impact to people. While we saw this often happened at night, the service’s rotas showed many different agency staff were working at the home during the day.

Staff told us there were not always enough staff, and this impacted people going out on activities at times, including when agency staff worked at the service. Comments included, “Always short”, “Some days there are staff shortages” and a person, “can't go out with agency staff so didn’t go out today”.

People’s relatives told us they were not sure if staffing levels at the home were sufficient. They told us, “Occasionally there seems to be under-staffing” and “There are never enough staff.”

The provider ensured staff had suitable employment checks undertaken before working in the service. This included identification checks, Disclosure and Barring Service Checks (DBS) and previous employment references. Profiles of agency staff recorded their completed training, employment checks and induction checklists.

Staff received regular supervisions. However, staff views of the support they received from managers varied. Comments included, “I don't get the support I need” and the interim manager was “very supportive.”

People’s relatives told us they were happy with the support provided to people by staff. Comments included staff were, “So good in supporting them, they’re kind and sensitive” and “Staff are kind and respectful.”

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

We found the service had made medicine management improvements following our assessment in June 2024. However, we identified some further improvements were still required during this assessment.

We found several gaps in people’s topical medicine administration records evidencing topical medicines were not being administered as prescribed. We did not find evidence anyone had come to harm because of this.

A new electronic system was being used to record medicines administration. However, the interim manager and staff were not able to access and find previous medicines information on this system. They could also not view body maps people had to record the position of their prescribed transdermal patches. This meant they could not be assured patch application sites were rotated to reduce the risk of skin irritation. The interim manager told us they had a further training session booked to learn more about the electronic system.

Senior leaders regularly completed medicines audits. However, these were not fully effective as the audits did not record if all people or specific people’s medicines records had been audited. It was also not always clear whether previous actions were in progress or had been completed. We fed this back to the provider.

Where medicine errors had occurred, medical advice had been sought and the error had been investigated. However, it was not always clear if any identified actions from the review of the error had been completed. This is important to ensure lessons were learned and shared to prevent similar errors occurring.

Information for staff about how to support people to take their medicines was detailed and included people’s preferences. Where people were prescribed as required medicines, for example when they may be in pain, there was clear information for staff to follow. Staff fully completed the controlled medicine log where people were prescribed controlled drugs.

Specific staff members had overall responsibility for daily medicines administration and checks of medicine administration records. These staff had received training to administer people’s medicines safely, and their competency to administer medicines assessed. Staff told us they were trained and confident in medicines administration. Staff told us, “I always follow the instructions for giving the medication” and “We do a 6 month review and competency check.”

However, we did see spoons used for the administration of medicines were dropped on the floor then returned to be stored with the other spoons. This posed an infection control risk. We fed this back to the provider to address.

We observed when people were being supported to take their prescribed medicines, staff explained what medicines people were taking and gained their consent before administration.