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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service demonstrated a positive and improving culture, with staff, management and the provider working towards a shared vision of improving outcomes for people. There was clear evidence of investment in the service since the previous assessment, including strengthened governance arrangements, environmental improvements, enhanced auditing processes and workforce development.

Staff consistently spoke positively about the support they received and described a collaborative working environment. One staff member told us, "We have a good staff team and the manager is available and supportive." Another staff member told us, "Everybody is involved and encouraged to raise anything. We can talk freely."

The management team were open, transparent and receptive to feedback throughout the assessment. Issues identified during the visit were discussed constructively, and action was taken where concerns were raised. Weekly management oversight reports were in place and provided detailed information regarding staffing, training, incidents, safeguarding and service improvements.

Feedback from relatives was positive and reflected confidence in the culture of the home. One relative described the service as "fantastic" and told us, "I know [my relative] is 100% safe here. I have no worries."

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Management demonstrated a strong commitment to improving the quality and safety of the service following the previous assessment. There was clear evidence of increased oversight through regular audits, weekly management reports, competency assessments and strengthened governance systems. Significant investment had been made to improve the environment, administrative support and quality assurance processes.

The registered manager and management team were visible throughout the assessment, they knew people well and worked collaboratively with staff and external professionals to support positive outcomes. They were open and transparent during the inspection, welcomed feedback and took immediate action where concerns were identified, including addressing environmental risks highlighted on the day.

Staff spoke positively about management and described a culture where support, training and development were encouraged. Staff reported feeling listened to and said management acted on concerns and suggestions raised within the service.

Relatives we spoke with consistently spoke highly of the leadership team, describing management as approachable, responsive and committed to delivering high-quality care.

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

The provider promoted a culture where staff felt able to raise concerns, share ideas and contribute to service improvements. Staff spoke positively about communication within the home and described management as approachable and responsive.

Staff consistently told us they felt comfortable discussing concerns and were encouraged to raise issues during supervisions, competency assessments and team discussions. They demonstrated a good understanding of safeguarding procedures and were aware of how to escalate concerns both within the organisation and to external agencies if required.

There was evidence feedback from staff had been listened to and acted upon. For example, staffing levels had been reviewed following concerns raised by staff, and workplace adjustments had been supported to help staff balance work and family commitments. Management meetings, group supervision sessions and staff communications were used to share information and drive improvement across the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider recognised and responded to people's individual backgrounds, needs and preferences. Care plans contained personalised information about people's life histories, cultural needs, preferred routines, communication methods, likes and dislikes, helping staff provide person-centred care.

Examples included records identifying a person's first language and communication needs, detailed "This is Me" documents, and care plans which reflected people's personal preferences, interests and choices. Staff demonstrated a good knowledge of people's individual needs and were able to explain how care was adapted to support them.

The provider also demonstrated a commitment to supporting staff. Staff spoke positively about flexible working arrangements and told us management were supportive when workplace adjustments were required. One staff member explained management had accommodated changes to their working pattern to support childcare responsibilities.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Governance arrangements had strengthened since the previous assessment and there was clear evidence of increased oversight across the service. A range of audits were in place covering care plans, medicines, accidents and incidents, health and safety, staff competencies and service performance. Weekly management reports provided oversight of staffing, training, incidents, safeguarding concerns and actions required, enabling leaders to monitor the quality and safety of the service.

Some of the provider’s audits needed to focus on people’s experiences to ensure they consistently received timely support and enhanced supervision and engagement within communal areas.

The provider had invested in additional management and administrative roles to support improvement and sustainability. This included the appointment of a dedicated administrator who was leading on policy reviews, audit processes and governance improvements. There was also evidence of ongoing investment in the environment, staffing and workforce development.

Management were able to identify areas requiring improvement and were receptive to feedback throughout the inspection. Where issues were highlighted, action was either taken immediately, or plans were put in place to address them.

We did identify some governance systems required further strengthening. We identified gaps in some audit records, inconsistencies in care plan review documentation, incomplete staff file audits and missed opportunities to submit notifiable incidents to the CQC. We also found some health and safety actions from the fire risk assessment had not been clearly tracked to completion.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked effectively in partnership with a range of health and social care professionals to support people's care, wellbeing and safety. Records showed regular involvement from GPs, District Nurses, Speech and Language Therapists, Mental Health Teams, Social Workers and other specialist services. Referrals were made appropriately and professional advice was reflected within care plans and risk assessments.

There was evidence of multi-disciplinary working to support people with changing needs, including those experiencing increased anxiety, weight loss, swallowing difficulties, falls and palliative care needs. The service maintained regular communication with relatives and involved them in care planning and reviews where appropriate.

Feedback from relatives was consistently positive, with family members describing good communication and saying they felt informed and involved in decisions about their loved ones' care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service demonstrated a clear commitment to learning and continuous improvement. Since the previous assessment, leaders had implemented a range of changes to strengthen oversight, improve quality assurance processes and address concerns identified through audits, incidents and feedback.

There was evidence lessons were learned from accidents, incidents and medication errors, with actions taken to reduce the risk of recurrence. This included additional staff training, competency assessments, safeguarding referrals and updates to care plans and risk assessments where appropriate.

The service had introduced and strengthened auditing processes across key areas, including medicines, care planning, health and safety and service quality. Regular management reports were used to monitor performance, identify trends and drive improvement.

Management were open to feedback throughout the assessment and demonstrated a willingness to reflect on practice and make changes. Examples included responding immediately to environmental concerns identified on the day and continuing to review policies.