Birkdale Residential Home

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.

At our previous assessment the provider was in breach of 2 legal regulations relating to safe care and treatment and safeguarding at the service. This was because the provider had failed to comply with fire safety regulations and the processes in place to assess people’s mental capacity were insufficient.

At this assessment, the provider had addressed the above concerns but remains in breach of these 2 legal regulations. This is because they failed to take all reasonable steps to manage risks to people and did not consistently share safeguarding concerns promptly.

This service scored 56 (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 always have a proactive and positive culture of safety where incidents were always investigated. Lessons were not always learnt to continually identify and embed good practice.

People’s risk assessments were not always reviewed following incidents to identify additional support people may need or to reduce the risk of the same incident happening in the future. The provider did not complete analysis of incidents, such as falls to look at possible patterns, causes, or risks associated with the incidents. We found no evidence of learning from accidents, incidents or safeguarding’s being shared with the staff team as a means of reducing the likelihood of recurrence. The registered manager told us they would discuss incidents with senior staff and if information was to be shared with care staff this was done via a group messaging facility. However, no evidence was provided to demonstrate that this had been carried out.

Staff knew the procedures to follow to report and record incidents and completed initial actions, such as obtaining healthcare, first aid and completing observations. However, we reviewed 21 accident forms staff had completed and found there was no evidence the actions taken had been reviewed by management. The registered manager told us they looked at the incident forms but did not record this.

The provider did not always manage or monitor people’s safety. They did not always make sure there was continuity of care when people moved between different services. Improvements were needed when people were discharged back to the home from hospital to ensure significant information was recorded and always passed to staff. One person was discharged from hospital with a significant injury however, their care records were not updated with this information. This placed the person at risk of further harm if staff were not aware of the injury.

When people were first admitted to the home, staff used healthcare partners assessment of their needs to help create risk assessments and a plan of care for them. The person, where able and their relatives also contributed to creating their plan of care.

The provider did not always share concerns promptly. They did not always take appropriate action without delay upon being alerted to potential abuse or potential improper treatment. The provider took 14 days to raise a safeguarding concern when they could no longer safely support 1 person. The provider also took 5 days to raise a safeguarding concern when unexplained bruising was found on another person. These delays in initiating safeguarding procedures placed people at an ongoing risk of harm.

The provider did not have effective systems and practices to make sure people were protected from abuse and neglect. The provider did not take appropriate action in response to recommendations made by the local Safeguarding Authority. Their recommendation was for the provider to have a designated staff member to analyse falls and decide if a safeguarding referral is required or not. The registered manager confirmed this had not been done. This placed people at potential risk of harm due to the absence of a structured approach to safeguarding decision-making.

Despite our findings for this assessment, people told us they felt safe living at Birkdale Residential Home and with the staff who supported them. Relatives told us they had no concerns about how staff safeguarded their family members. Care staff understood how and when to share concerns with senior staff and the registered manager. They told us they had completed training in safeguarding.

The provider did not always work well with people to understand and manage risks. Although people’s risks were assessed, the associated records were not always kept updated when these risks changed. One person’s care plan stated they had experienced a number of recent falls, so staff were to monitor their mobility day to day. However, the care plan did not give any guidance for staff on how this monitoring should be carried out. This lack of clear arrangements to support the person’s changing needs put them at an increased risk of harm.

The registered manager told us people’s risk assessments were reviewed monthly unless there was a significant incident. However, we identified occasions when safeguarding referrals had been made due to unexplained bruising or falls. Risk assessments, although reviewed, were not updated with this information. They also did not contain any review of how risk could be minimised in light of these incidents. This placed people at risk of harm.

Despite this, staff provided supportive care and knew people well. They told us they received the support they needed from the registered manager and senior staff to deliver safe care. One staff member told us they were asked for their feedback when people’s care files were reviewed. They explained that care staff contributed to care reviews due to their daily involvement in supporting people. This helped to ensure up to date information was gathered prior to updating care files.

Relatives told us they felt involved in their family member’s care. They were able to speak with staff if they had any questions or concerns and staff kept them updated on incidents which had affected their family member, such as a fall.

People were cared for in a safe environment. Improvements had been made to the fire safety systems and the environment of the home. Risks associated with the premises and equipment were managed through a programme of safety checks and maintenance at the home. This included areas such as ensuring equipment was in good working order and all utilities were serviced and safe.

We identified the screws on the home’s window restrictors were not tamperproof, therefore not safe. The provider replaced these following our assessment and provided evidence to us to confirm this action was completed.

Staff received effective support, supervision and development opportunities. Staff worked together well to provide care that met people’s individual needs. Staff told us they were up to date with appropriate training which was relevant to their role. However, the provider’s training matrix had not been updated since May 2025 and did not reflect all the training staff had received. The registered manager updated the training matrix after our site visit to ensure accurate staff training was recorded.

People told us they were not kept waiting when they needed support from staff, which is an indicator of effective staffing numbers.

The provider’s recruitment procedures were safe. They made sure the required pre-employment checks had been completed prior to staff working with people at the home. This helped to ensure only suitable staff were employed.

The provider managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected as much as possible from the risk of infection because the premises and equipment were kept clean and hygienic. Staff told us they had access to enough personal protective equipment (PPE) and we saw hand sanitiser points and PPE stations around the home. Staff also had sufficient hand washing facilities available to them with signage to remind them the correct hand washing technique. Visitors to the home were able to wash their hands as they arrived because the reception area contained hand washing facilities.

People and relatives told us they had no concerns about the cleanliness of the home.

We identified some specific protocols were not in place for when people needed their medicine as required. When we returned on day 2 of our assessment, these were in place. Senior staff told us these had previously been in place but may have been misplaced during GP visits. We also found an unaccounted tablet for 1 person, which was loose in the packaging box. This medicine was all signed for as administered and the number of tablets was correct, so the provider could not be assured the person’s medicine had been administered as prescribed.

Staff ensured people received medicine reviews by their GP. One person’s relative told us they had recently had a medicine review by the GP and was now, “Much better and more alert.”

However, the provider had made improvements since our previous assessment, and we noted there had been less medicine errors. Where 1 person was running out of medicine, we saw staff had tried to restock prior to running out and had been proactive in their attempts to avoid missed doses. Medicines were stored safely, and people received their medicines as prescribed. Medicines stock counts took place, and 2 senior staff had been trained to complete medicine competency assessments on other staff. The improvements in medicine managements helped to ensure people received their medicines as prescribed.