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 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.

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

This service scored 50 (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 consistently uphold transparency in the way information was managed and shared. Learning from incidents and subsequent trend analysis were not always documented. There was minimal evidence of these being reviewed or discussed as a staff team to help prevent reoccurrence of trends. As a result, opportunities for collective learning and risk reduction were limited.

Since our previous inspection, new systems and processes had been introduced to the way safeguarding, accidents and incidents were managed. These new processes had been shared with staff. As these changes were recent, we were unable to confirm they were fully embedded or contributed to measurable improvements. We noted a recent incident form and the actions taken had not been authorised by the registered manager, so we were not assured this incident had been reviewed in line with their new process.

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. One staff member told us, “We treat everyone like they are part of our own family and that is the values all staff promote.” Staff worked well together, and this reflected on how well they treated people and their visitors. The registered manager was supported by 2 care co-ordinators, and together, they had put into place several improvements since our previous inspection.
 

At the previous inspection, we identified there was no provider oversight of the registered manager or the service. They did not receive any regular supervision or have any support mechanisms to help them access development in their roles. At this inspection, we found nothing had changed. The registered manager was also the nominated individual of the service and had recently received some training for this role. A nominated individual has responsibility for supervising the way the regulated activity is managed. This meant there was no independent oversight of the service. Without sufficient oversight, the provider cannot be assured risks to people were being consistently and appropriately managed by staff, or robust governance arrangements were effectively driving improvements within the service.

Staff told us they felt supported by the leaders at the home. One staff member told us, “I feel there has been improvements recently, the environment is better and we know what we are supposed to be doing.” Another staff member told us the registered manager was, “really good at ensuring people have what they need.” This included making sure people had essential items such as toiletries and appropriate clothing.
 

The provider fostered a culture where people felt they could speak up and their voice would be heard.

Staff were confident to speak up if they had concerns about the service. One staff member said, “I am aware of whistleblowing and would have no hesitation in doing so, but I feel confident if I raised any concerns I would be listened to.” The registered manager told us they had an open-door policy so staff could speak with them at any time if they had concerns.

The service had systems and processes in place to enable staff to speak up. A policy was in place to support staff in speaking up about unsafe care and this is known as whistleblowing. The policy signposted staff where to go for support and the processes to follow to support them to speak up.
 

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 needed to ensure further and sustained improvements were made within the service. This was the fourth consecutive inspection in which there had been a breach of regulation relating to governance, and the provider had not achieved a rating of ‘good’ in well‑led for at least 10 years. Improvements made following previous inspections had been implemented in isolation, without sufficient planning or a long‑term approach to embed change. This lack of strategic oversight meant the provider risked repeating the same quality issues and did not consistently learn from previous inspections or sources of quality assurance.

At the previous inspection, the provider lacked robust governance systems to ensure compliance with regulatory requirements. At this inspection, similar concerns remained. While audits were carried out in most areas, they did not consistently identify gaps in practice or opportunities for learning. A recently completed medicine audit recorded medicine room and medicine fridge temperatures had been completed, but this was not the case. The registered manager told us they discussed and analysed safeguarding concerns, falls trends, and health and safety audits with senior staff; however, there was no documented evidence to support this. This lack of documented oversight represents a significant failure in governance and placed people’s health, safety, and welfare at potential and avoidable risk of harm.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

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. Staff made sure timely and appropriate referrals were made to external agencies, whether for healthcare needs or for reporting any concerns.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system.

At this inspection, we identified shortfalls in areas such as medicines and quality assurance processes, which were similar to concerns found at our last inspection. The registered manager and senior staff were open to feedback we gave throughout the inspection and showed a willingness to improve. However, the provider’s overall approach had not been sufficiently effective in driving the sustained and necessary improvements required to meet regulatory requirements.

The registered manager had a service action plan in place. This was based on input from external professionals and their recommendations following recent visits to the service, including our previous inspection. Although many actions had been signed off as completed, the plan did not demonstrate evidence of sustained improvement or robust monitoring to ensure these actions had been fully embedded in practice. There was no evidence the provider had oversight of the action plan to ensure the completed actions had effectively addressed the concerns or reduced associated risks.