Birchwood & Co Case Management Ltd

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.

This is the first assessment for this newly registered service. This key question has been rated 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. Managers and staff told us they were committed to providing people with the best possible quality of care and support and described a shared focus on delivering care that was person centred and responsive to individual needs. Staff understood their role in supporting people to achieve positive outcomes. Leaders demonstrated a good understanding of their regulatory responsibilities and were aware of the key priorities for the ongoing development of the service. They were able to describe plans to improve and strengthen practice, and systems were in place to support learning, development, and continuous improvement.

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. Systems and processes were in place to provide support to staff, including access to management support, training, and opportunities to raise concerns or seek guidance. Staff told us they generally felt supported in their roles, which helped to promote a positive, open, and inclusive workplace culture. Some staff commented that they would welcome additional opportunities for face‑to‑face meetings, training and team‑building activities, as they felt this would further strengthen peer support, communication, and team working.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies and procedures were in place to guide people and staff, including safeguarding and whistleblowing policies. We reviewed records that demonstrated people’s views had been actively sought, including through surveys, complaints, and compliments. Overall staff told us management were approachable, and they felt comfortable speaking with them and raising concerns. One staff member told us, “I feel that if I raise any concerns I am listened to and supported by management.”

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. Policies and procedures were in place that promoted equality, diversity, and inclusion, and staff received appropriate training. Feedback and documentation reviewed confirmed that reasonable adjustments were available to support staff’s individual circumstances if required.

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. However, during our assessment, we identified that two people receiving the regulated activity of personal care may fall within the learning disability and/or autism service user group, for which the provider was not currently registered. We found that the service needed to review some areas of delivery to ensure full compliance with the principles of ‘Right support, right care, right culture’ in relation to this service user band. The provider confirmed they would submit an application to CQC to vary their registration to include this service user group and ensure full compliance with the principles of ‘Right support, right care, right culture.’ The provider was aware that they should not accept any further people requiring the regulated activity of personal care under this service user band until the application had been approved. The provider had effective structures and governance arrangements in place to monitor, review, and improve the quality of care delivered. Systems such as audits and quality monitoring processes were used to assess the quality and safety of the service. The introduction of a new electronic system was expected to strengthen governance and provide improved service wide oversight. The registered managers demonstrated an understanding of their regulatory responsibilities, including the duty to notify relevant partners although no notifications had been required during the period reviewed.

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 demonstrated a clear commitment to continuous improvement and actively sought opportunities to enhance the quality of care provided. They were open to feedback and welcomed suggestions for development, reflecting a proactive and reflective approach to service improvement. The provider also recognised the importance of collaborative working and maintaining effective relationships with partner organisations to support coordinated care and positive outcomes for people using the service. One partner commented, “[Staff name] empathised and advocated for our client in a difficult situation to secure what they needed.”

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 provider outlined clear plans to develop the service and improve outcomes for people. These plans were informed by learning, reflection, and feedback and demonstrated a forward‑looking approach to service development. Systems were in place to learn from incidents and near misses, with records showing that lessons learned were identified, shared with staff, and used to reduce the risk of reoccurrence. Policies and procedures were regularly reviewed to ensure they reflected current best practice and were accessible to staff.