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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The management and staff culture demonstrated positive learning, with evidence lessons were learned from incidents, audits and feedback from partners, professionals and people. Since the previous assessment, significant investment had been made in strengthening governance, quality assurance and oversight arrangements.

Accidents, incidents and safeguarding concerns were routinely reviewed, with appropriate actions taken to reduce the risk of reoccurrence. Comprehensive audits were in place across the service, including care planning, medicines and health and safety, with identified concerns leading to improvements in the service provided.

Management were open and receptive to feedback throughout the assessment, addressing issues promptly and taking immediate action where concerns were identified. Staff described a supportive culture where training, competency assessments and reflective discussions were used to drive improvement.

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.

People's needs were managed through effective care planning and close partnership working with health and social care professionals. Referrals were made promptly when concerns were identified, and there was evidence of ongoing involvement from GPs, District Nurses, Mental Health Teams, Social Workers and other specialists.

Care records showed people received appropriate support when their needs changed, including following falls, health deterioration and behavioural changes. Appropriate arrangements were in place to support people moving between services to ensure continuity of care, with emergency information, care records and evacuation plans being readily available.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Whilst safeguarding processes were mostly effective, opportunities remained to strengthen oversight of statutory CQC notifications to ensure all notifiable incidents were reported appropriately and in a timely manner.

People were safeguarded from the risk of harm. Staff had completed safeguarding training and demonstrated a good understanding of safeguarding responsibilities, recognised the signs of abuse and were confident in escalating concerns internally and to external agencies where required.

Records showed safeguarding concerns were appropriately reviewed by the safeguarding lead, with clear decision-making, actions and rationale documented. Where incidents occurred, appropriate action was taken to protect people and reduce the risk of recurrence. For example, following a medication error involving epilepsy medication, the member of staff was stopped from administering medicines, safeguarding procedures were followed and additional training and competency assessments were completed. Similarly, where a medication administration omission was identified through audit processes, immediate action was taken, healthcare professionals were contacted and safeguarding referrals were made.

Accident and incident records demonstrated concerns such as falls, skin tears and medication errors were investigated, with follow-up actions implemented and professional advice sought where required.

Management had effective oversight of Deprivation of Liberty Safeguards (DoLS) arrangements and were able to clearly describe the circumstances in which a DoLS authorisation would be necessary. No people using the service were subject to conditions under an authorised DoLS at the time of inspection.

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

People were involved in managing risks associated with their care and support. Care plans and risk assessments were personalised, regularly reviewed and reflected people's preferences, routines and choices. Records demonstrated people and, where appropriate, their relatives were involved in care planning discussions and reviews.

Risk assessments provided clear guidance for staff whilst promoting independence. For example, 1 person's falls risk assessment had been updated following recent falls, with evidence healthcare professionals had been contacted, advice sought and care plans reviewed to reduce further risks. Another person's behaviour support plan clearly identified triggers, early warning signs of anxiety and the actions staff should take to support them safely and reduce distress.

Staff demonstrated a good understanding of people's individual risks and needs. One staff member told us, "The care plans are very good to follow and tell you what you need to know.” Another staff member told us, "We all make sure the residents get perfect care here."

There was evidence of regular multidisciplinary involvement to help manage risk. For example, professionals were involved in supporting people experiencing increased anxiety and behavioural distress, weight loss, swallowing difficulties and deteriorating health needs. Where risks changed, records showed appropriate referrals were made and care plans updated accordingly.

Feedback from relatives we spoke with also reflected confidence in the provider’s approach to managing risk. One relative told us, "I know [relative] is 100% safe here. I have no worries and I couldn't be happier."

The provider detected and controlled potential risks in the care environment. They mostly made sure equipment, facilities and technology supported the delivery of safe care.

During this assessment, some environmental issues were identified, including unsecured wardrobes, missing room identification on some bedroom doors, a damaged curtain pole and outstanding health and safety actions relating to fire risk assessment and Legionella monitoring. Management responded positively to the feedback, with some actions addressed immediately during the assessment.

The provider had invested in improvements to the premises and was undertaking ongoing refurbishment and decoration work to enhance the living environment. Essential safety checks were in place, including gas safety, fire safety, lifting equipment servicing, PAT testing and business continuity arrangements.

Regular environmental audits were completed, and actions were taken to address identified concerns. For example, air conditioning was being installed in the medication room following a medicines storage incident during the recent heatwave and the need to store medication at a certain temperature.

The environment was generally safe and there was evidence of continued investment and maintenance, although further work was required to ensure all environmental risks were identified, monitored and addressed in a timely manner.

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.

People were supported by enough staff who understood their needs and risks. At the time of this assessment, staffing levels included 1 senior and 4 care staff during the day, alongside dedicated activities, catering, domestic, laundry, maintenance and administrative staff. The registered manager was supernumerary and available to provide oversight and support.

Staff spoke positively about staffing levels and the support they received. One staff member told us, "No problems with staffing. We have enough to meet residents' needs." Another staff member told us, "I am very happy working here. We have a good staff team, and the manager is available and supportive."

Training, supervision and competency assessment processes were in place. Medication competency assessments were detailed and identified both strengths and areas for development. Staff confirmed they received regular supervision, competency checks and refresher training. One staff member told us, "The training is very good, and you get chased when refresher training is due."

Recruitment records showed appropriate pre-employment checks were completed, including references, DBS checks and health declarations. However, some records did not demonstrate original identification documents had been signed and dated when verified. We also identified some gaps in the completion of staff file audits. The registered manager took our feedback positively and added to the improvements of the governance systems.

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

People were protected by effective infection prevention and control systems. Staff had access to appropriate training, policies and personal protective equipment (PPE), and the home completed regular cleaning and environmental checks.

Records showed infection risks were identified and managed appropriately. For example, risk assessments were in place for people with specific infection control needs, including MRSA, and staff were provided with guidance on how to minimise the risk of transmission. Healthcare professionals were involved where required, and care plans reflected people's individual health needs.

During this assessment, minor environmental issues were identified, including cleanliness concerns relating to a bathroom ventilation unit and a commode. These were brought to the attention of management, who responded positively to the feedback.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified discrepancies relating to topical medicines, including instances where application records did not consistently correspond with topical medication administration charts. In addition, a handwritten entry for a topical medicine was recorded on 1 MAR chart but was not clearly reflected within supporting records or identified as a prescribed PRN or homely remedy.

During this assessment, medicines were temporarily being stored in an alternative location due to installation works. Although arrangements were in place, we found the temporary storage area needed to be more robustly secured. We also noted the key to the medicine’s fridge had been left in the lock and the staff member administering medicines was unable to clearly state the acceptable temperature range for medicines storage, despite records showing temperatures remained within range.

Since the previous assessment, the provider had made significant improvements in medicines management. People's MAR charts were well completed, detailed guidance was available regarding how individuals preferred to take their medicines, allergies were clearly identified, and regular audits of medicines, controlled drugs, fridge temperatures and MAR charts were taking place. Medication competency assessments were detailed and demonstrated improved oversight of staff administering medicines.

Where medication errors had occurred, investigations had been completed, safeguarding referrals made and action taken to reduce the risk of recurrence, including additional training and competency assessments.