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, and ensuring improvements identified were made in a timely manner.

The provider was previously in breach of the legal regulation in relation to governance. Although some improvements were found at this assessment, the provider remained in breach of this regulation.

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 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.

The service had not ensured they had assessed all risks to people or ensured people’s risk assessments were updated when their needs had changed.

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 dehydration or pressure damage. They had not ensured the system they used to regularly review people’s care was effective in identifying where people’s documentation required updating.

The provider had identified most of the shortfalls we found at our inspection through their internal quality assurance audits, and actions were listed in a service improvement plan. However, this had not resulted in the necessary changes being made in a timely manner.

The service did not have a registered manager in post. A service improvement manager was currently managing the service. The manager’s office had moved into the main area of the home. The manager was observed to be actively overseeing care delivery and providing direction to staff. Staff and adult social care professionals were positive about the manager’s approach. A professional told us, “The current manager is a very visible presence in the home.”A staff member said, “With the interim manager we are allowed to raise concerns, we have raised lots of things and there have been lots of changes, it is positive.”

The service had quality monitoring systems. This included daily checks, monthly audits and provider audits to provide operational management with oversight of the service. The manager had a service improvement plan to drive improvements. Actions were prioritised according to risk, and the manager had weekly meetings with a regional director to review progress.

The manager was auditing people’s care notes and reviewing the activities being provided to people. They acknowledged more improvements were still required, which they were working on.

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.

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.