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.

The service was in breach of legal regulation in relation to the way people’s medicines were managed safely.
 

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Concerns highlighted at our previous inspection around the oversight and analysis of accidents and incidents were still evident. Although the provider had taken steps to strengthen their systems, these improvements had not yet resulted in a consistently embedded learning culture across the service. Individual incidents were shared with staff during shift handovers; however, collective learning, discussion and analysis of emerging themes or trends were not apparent.

Staff knew the procedures to follow to report and record incidents and completed initial actions, such as obtaining healthcare, first aid and completing observations. Individual incidents, including safeguarding concerns, were reviewed, and actions were identified to reduce the risk of similar incidents occurring again.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

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 worked with external healthcare professionals to support people’s care and help to keep them safe. This collaborative approach helped to ensure people received coordinated, joined‑up care across different services. One health professional told us, “Staff are very approachable, we often have open discussions around care and what works best for that patient at that time.”
 

At the previous inspection, the provider had not consistently shared concerns promptly with healthcare professionals or the local safeguarding authority. At this inspection, we found evidence this was now being carried out appropriately. However, the provider needed to make further improvements to ensure safeguarding outcomes were formally recorded once their internal investigations were completed. We asked to see the providers report after a recent internal investigation they had completed into safeguarding allegations. We were told no report had been produced, despite the investigation having taken place. The outcome had been sent to the local safeguarding authority via email. The provider could not clearly evidence the rationale for decisions, or how outcomes had been reached. This also limited their ability to identify learning and provide effective oversight of safeguarding concerns.

The provider had made some improvement to safeguarding practice and processes. The provider’s safeguarding policy had been updated and staff now had clear information on when to make referrals to the local safeguarding authority.

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 and had completed training in how to safeguard people.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff worked with health professionals to ensure these were completed. When people needed help to make decisions, staff recorded how choices were made in the person’s best interests.
 

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At the previous inspection, people’s risks were assessed, but records were not always kept updated when these risks changed. At this inspection, risks to people were assessed and reviewed regularly to help ensure they remained relevant to the person. Records were kept updated and reviewed to determine if risk could be minimised in light of any incidents which had occurred. Where possible, people and their relatives were involved in reviewing their care.

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.
 

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 made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the previous inspection, the provider’s training matrix was out of date and did not accurately reflect the training staff had completed. At this inspection, the matrix was up to date and demonstrated staff had received training appropriate to their roles.

People told us they were not kept waiting when they required support from staff. We saw there were sufficient staff to promptly and safely support people when they needed it. This demonstrated staffing levels were sufficient to meet people’s needs in a timely manner.

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

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 provider did not make sure medicines and treatments were managed safely.

At the previous inspection, we identified concerns relating to the safe management of medicines. While those specific issues had been addressed, we identified new and significant concerns in other areas of medicines practice.

Staff did not consistently sign medicine administration records to confirm prescribed medicines had been administered in accordance with the prescriber’s directions. Medicine administration records (MARs) for January 2026 contained numerous omissions. This failure created a risk to people’s health and wellbeing, as it could not be reliably confirmed whether medicines had been administered as prescribed.

The registered persons had not ensured the medicine room and fridge temperatures were recorded daily. To ensure medicines were safe for administration they must be stored as directed by the pharmaceutical manufacturer. Failure to store medicines safely could lead to them being ineffective and compromise people’s health. Where the temperature checks had been recorded, these were within the appropriate range.

Although we found no evidence of direct impact on people, the provider was unaware of this unsafe practice until we brought it to their attention. Despite the provider having completed checks on medicines management, these concerns had not been identified.