Birch Green Care 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.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Staff recorded incidents onto the electronic system, and the registered manager reviewed them to identify any issues with practice or care delivery, so that improvements could be made. There was an appropriate incident recording policy with a clear structure to oversee and monitor concerns. The registered manager provided examples of when changes had been made following an incident, such as changes in communication pathways to improve end of life care.

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.

There was an appropriate pre-admissions policy and an effective pre-admission process. This helped to make sure staff had the right information about people in order to meet their needs when they moved in to Birch Green Care Home. We saw evidence of referrals and effective communication to external healthcare agencies to support people’s health outcomes.

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.

Staff completed safeguarding training and knew how to raise safeguarding concerns. There was an up to date safeguarding policy and clear information available to staff. The registered manager maintained a record of all safeguarding referrals and investigations, and made sure any recommendations were implemented. People said they felt safe living at the service.

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.

The registered manager assessed risks to people’s health and wellbeing and reviewed these regularly. People and their relatives were included where appropriate. A relative said, “I have had input around my [relative’s] care from the beginning, including being on ward rounds with the doctors.”

Staff undertook training about how to support people during periods of distress; they had good knowledge about what may cause anxiety for some people and knew how to reassure people well.

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

The provider undertook health and safety checks and had compliance certificates for gas safety, electrical, water and fire safety.

There was a full-time maintenance manager on site who conducted environmental audits and made sure items were replaced or fixed when required.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

The provider used a staffing dependency tool to make sure there were enough staff to meet people’s needs. The provider recruited staff using safe processes and made checks such as references and disclosure and barring service (DBS) checks. Staff completed training required for the role and compliance rates were high.

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.

There were dedicated housekeeping staff who adhered to cleaning schedules, and we found the home to be clean and tidy. Staff wore appropriate protective clothing, and we observed staff washing their hands. Relatives commented they thought hygiene was maintained to a high standard.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored securely and according to guidance. Staff signed to say they administered people’s medicines according to their prescriptions. There was an effective stock control management system. There was clear and detailed guidance in care plans about how to administer medicines safely, including for medicines that were prescribed ‘as and when required.’

The management team checked staff competencies around the administration of medicines and made sure nurses’ registration was validated.