Birkdale Residential Home

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 inadequate. 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.

At our previous assessment the provider was in breach of 1 legal regulation relating to the governance of the service. At this assessment, the provider has not made enough improvement and remains in breach of this legal regulation.

The provider was also in breach of 1 legal regulation in relation to notifying us of specific events at the home.

This service scored 39 (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 had not demonstrated a culture of learning across the service and had failed to identify weaknesses in their governance systems. They had failed to act on feedback provided by the local safeguarding authority who had recommended they implemented a process for analysing falls and determining whether safeguarding referrals were required. The registered manager told us they had not done this. This demonstrated a lack of commitment to learning from incidents and a culture where reflection and accountability were not actively promoted.

The registered manager had taken steps to address concerns raised during our previous assessment, this assessment confirmed most of those specific issues had been resolved. However, at this assessment we also identified new areas of concern. This lack of continuous learning and improvement can impact on people’s health, safety and wellbeing.

Staff at Birkdale Residential Home had created a positive culture where they understood equality and diversity and provided care to people in a compassionate way. Staff morale was good, and staff were complimentary about the support they received from senior staff and the registered manager.

Senior staff told us they had recently achieved the NHS Care to Smile award, which as a home they were proud of. They were mouth care leads for the home and had been trained to enhance the knowledge and skills of the care staff to deliver effective oral care. Care to Smile is an NHS programme designed to improve the oral health of residents in residential and nursing care homes and provides care homes with tailored resources and ongoing support.

The provider had made improvements since our previous assessment to the environment, fire safety, auditing and changes to staff responsibilities. Despite this improvement, leaders needed to ensure further, and sustained improvement was made. The registered manager had delegated responsibilities to senior staff for specific aspects of the service, such as safeguarding and falls management. However, they had not ensured the staff had the knowledge to complete all these responsibilities in accordance with legal regulations, such as notifying us of specific events. There was a failure by leaders to have clear oversight of the service. By not having the necessary oversight of the service, leaders could not ensure risks were well managed by their staff.

We also identified that some responsibilities had not been delegated when staff went off work for a period of time. The registered manager told us they were aware of this. This demonstrates a significant gap in governance and risk management.

The registered manager was also the nominated individual of the service. A nominated individual has responsibility for supervising the way the regulated activity is managed. They also play an important role in the leadership of their service and driving improvement through robust governance. We identified there was no oversight of the registered manager, they did not receive any regular supervision or have any support mechanisms to help them access development in their roles. We identified gaps in their knowledge in relation to their regulatory responsibilities, such as when to notify us of incidents.

While staff were aware of how to raise concerns, they lacked consistent and structured opportunities to do so. The registered manager told us no face-to-face staff meetings had taken place since May 2025. These had been replaced with a group messaging facility. The registered manager told us staff surveys were “ad hoc” and were used when new ideas were introduced, such as getting staff opinion on the carer of the month initiative recently introduced. This lack of regular engagement would restrict staff’s ability to raise concerns or share feedback.

The registered manager told us they had an open-door policy so staff could speak with them at any time if they had concerns.

A policy was in place to support staff in speaking up about unsafe care and this is known as whistleblowing.

Staff told us they worked well as a team and helped and supported each other. One staff member told us, “We have a nice selection of staff, and the seniors will muck in with personal care when needed.” New staff had mentors who supported them through their induction into the home and roles. The registered manager supported staff who needed flexible working arrangements to help them accommodate personal commitments. One staff member told us the registered manager was, “Fair and flexible with rotas.” This approach fostered a supportive work environment and contributed to staff well-being and retention.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A lack of provider oversight meant that areas of concern we found during our assessment had not been identified. Key issues, such as safeguarding referral delays and a lack of follow-up on external safeguarding recommendations were either missed or not acted upon. People’s care records did not always include significant information such as the support they needed following falls and injuries and how to reduce future risk. There was also no evaluation of patterns, causes, or risks associated with incidents at the home. People were put at risk because the provider’s governance systems did not ensure the safety and wellbeing of people.

We reviewed 21 accident forms. The accident forms included a section to “describe what steps had been taken to reduce the risk of the accident/incident re-occurring” and to “describe what could be done to reduce the risk of the accident/incident occurring again.” However, none of the forms contained any information indicating that the incidents had been reviewed or that consideration had been given to minimising future risk. People’s health, safety and wellbeing were compromised because of the failure to engage in post-incident analysis on how accidents had been handled.

The provider had failed to submit statutory notifications to us as required. These ensure we are aware of important events and incidents that affect services or the people who use them. Providers have a statutory responsibility to submit these, and they provide us with crucial information to monitor the quality and safety of services. The provider did not notify us of Deprivation of Liberty Safeguards (DoLS) or of safeguarding concerns which affected people in the home. Failure to submit these notifications prevents us responding to potential significant incidents and taking action to protect the welfare of people.

The provider had made some improvement to other aspects of their governance systems since our previous assessment. We found audits were more effective and systems had been put in place to ensure the environment; fire safety and maintenance of the building and equipment were monitored. People’s assessment of capacity and associated best interest decisions were improved along with staff understanding of these processes. The provider needed to ensure continued and sustainable improvements throughout all their governance systems to ensure people’s health, safety and welfare was continually maintained.

Staff worked in partnership with external healthcare professionals to help ensure people’s needs were met. A weekly virtual meeting took place with the GP and other healthcare professionals where staff could discuss people’s health concerns. However, records did not demonstrate all incidents were discussed with health professionals and not all feedback was acted on in a timely manner.

One healthcare professional told us they had no concerns regarding the service. They noted that, during their visits to the home, staff were aware of the reason for their attendance and had access to the necessary information about the person. They were confident with staff ability and that they made appropriate contacts with the GP practice when people’s health needs changed.

The local authority told us, since our previous assessment they had visited the home numerous times. This was to meet with the registered manager and support them to improve the quality of the service to meet the quality standards of the local authority. The registered manager also attended their monthly drop-in sessions which were held by the safeguarding and DoLS teams. These drop-in sessions were an opportunity for advice and support. The local authority told us they had seen a gradual improvement in the service and the staff team had worked well with them, their internal DoLS team and other partners, to improve the quality of the service provision.

The provider did not have adequate systems for reviewing and investigating when things went wrong. They did not demonstrate learning or identified themes and actions to improve safety in the service. Staff recorded when people had fallen on a tracking tool, but it was not used to evaluate patterns, causes, or risks associated with the incidents. The registered manager told us they were aware they had not delegated this responsibility. This demonstrated a significant gap in governance and risk management, undermining the provider’s ability to protect the health, safety, and wellbeing of those in its care.

The provider had demonstrated some evidence of learning and improvement from our previous assessment. The provider had updated fire systems, started a refurbishment of the whole home and installed new electrics throughout. The registered manager shared plans with us for further improvements.

Following feedback from a recent Healthwatch visit, the registered manager had implemented a “You Said, We Did.” notice board in the entrance to the home. The notice board encouraged people, visitors and staff to write suggestions for improvement. 'You Said, We Did' is a phrase used to describe initiatives where organisations actively listen to feedback, take action, and then share the results. The registered manager told us that although there were no suggestions yet, they were hopeful people, visitors and staff would engage with it.

The registered manager and senior staff were open to feedback we gave throughout the assessment and showed a willingness to improve.