Birnbeck House - Care Home Learning Disabilities

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 requires improvement. At this assessment the rating has remained 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.

We found improvements were needed to the provider’s governance arrangements around risk management, training, and reviewing the quality of people’s care.

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

This service scored 62 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The provider did not have effective systems to identify the shortfalls we found at the inspection in relation to good governance. The provider had not ensured effective systems were followed and monitored to ensure people were not placed at risk of potential harm in relation to choking. The provider had not ensured staff were always appropriately trained for their roles, or the service had effective monitoring systems to identify shortfalls in the provision of people’s daily care and support to maintain their health and wellbeing.

The service did not have a registered manager in post. The service was being supported by an interim manager and a senior management team. People’s relatives, staff and professionals told us there had been a lot of staff changes, and a lack of stable management at the service.

The service had quality and monitoring systems. This included daily checks, monthly audits and provider audits to provide operational management with oversight of the service.

However, these audits had not identified the shortfalls we found during our assessment. For example, daily manager checks and mealtime audits did not record people’s experience. Such as how long people waited to be supported to eat their meals or how staff were engaging with people. People’s daily records and forms put in place to monitor people’s 1 to 1 support and activities were not being audited to identify if people were being supported in line with their risk assessments and care plans or to ensure people were provided with their funded support or meaningful activities.

The provider did not maintain an effective oversight of the quality of care being provided, risk management and mitigation and staff training. For example, the service did not have a system to check measures identified to reduce the risk of people choking in the service’s risk of choking audit were being implemented. 2 staff who had worked at the service for over a year had not completed their required learning disability and autism training. It was not clear what measures the service had to develop a supportive learning culture for staff or how staff were being engaged to improve person centred care for people.

However, the provider had a business continuity plan, to guide staff in emergency circumstances.

Staff and relative surveys had been completed to seek feedback and action plans developed from the results. The service used a range of meetings to ensure staff were kept up to date with any changes to people’s care, these included team meetings and flash meetings. A flash meeting is a short staff meeting where recent events and changes to people’s care are discussed.

Adult social care professionals told us they felt the management team were approachable and things had generally improved for people. Comments included, “The management have worked well with health professionals” and “I would say that in 2024 the service was not well led but Leonard Cheshire have put in 2 good managers who have worked on this.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.