Birkdale Court

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 newly registered service. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 59 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Lessons learned from accidents and incidents were not being consistently captured or reviewed. The service did not always analyse events to identify trends or patterns that could reduce future risks. Staff did have systems available to raise concerns, and managers responded to these on an individual basis. However, the organisation did not record or evaluate learning from incidents, and there were no formal debriefs documented following accidents or incidents. Staff told us, “Debriefs do not usually happen, it depends on the severity of the incident.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

Preadmission assessments and transition planning were robust and ensured people experienced a safe and well-coordinated move into the service. The registered manager completed thorough assessments before anyone was admitted, enabling the service to fully understand people's needs in advance. One relative said “The preadmission was great; everything was in place for when they arrived. They were brilliant through the full process. They had all the information they need.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

The service was not always working in line with the Mental Capacity Act (MCA). People were only deprived of their liberty when this was in their best interests and legally authorised through the Deprivation of Liberty Safeguards (DoLS). Appropriate DoLS authorisations were in place for people who lacked capacity. However, people’s mental capacity was not always assessed appropriately and best of interest’s decisions were not always completed for people.

Staff had the skills and knowledge to identify and report safeguarding concerns and where confident appropriate action would be taken by the management team. Safeguarding concerns had been suitably reported to relevant professionals, and action taken to safeguard people. People’s relatives were reassured by support provided and all the relatives we spoke to feel the service was safe.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Risk assessments were in place but not always followed in practice, which placed people at avoidable risk. People had risk assessments that covered key areas such as mobility, nutrition and hydration, and skin integrity. These assessments were reviewed regularly and were up to date. However, daily records identified that staff did not consistently follow the guidance set out in these assessments. For example, two people required regular repositioning, and this was not completed in line with their individual risk assessments.

The provider had effective systems in place to identify and manage environmental risks, helping to ensure people received safe care. Equipment, facilities, and technology were monitored and maintained to support safety. Regular checks were carried out across the care home to ensure the environment remained safe. Personal Emergency Evacuation Plans (PEEPs) were stored in an accessible emergency grab bag.

The provider could not demonstrate that safe recruitment practices were consistently followed. Recruitment processes were not always robust, as staff were interviewed by only one person and records of probationary reviews were inconsistently maintained. In addition, information relating to agency staff was not consistently documented. Not all agency staff had a pen picture in place detailing their experience and training, and records did not demonstrate that all agency staff had received an induction to the service.

These findings were not in line with the provider’s own agency staffing policy and meant we could not be assured that appropriate recruitment and pre-employment checks had been completed for all staff working at the service.

The provider acknowledged these shortfalls and shared plans to strengthen recruitment oversight, improve record-keeping, and ensure agency staff documentation and induction processes are consistently completed.

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.

The provider had effective infection prevention and control (IPC) measures in place. Monthly IPC audits were completed to monitor compliance and identify any areas for improvement. Staff followed an IPC policy that aligned with current good practice. Staff had received training in infection prevention and control and used personal protective equipment (PPE) appropriately. Staff told us PPE was always available, and they were able to describe the different situations in which PPE should be used.

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

The provider did not consider all medicine related risks. For example, the service did not always have individual fire risk assessments in place for people who were prescribed paraffin-based skin products. Thickeners used to thicken fluids for people with swallowing problems were not recorded when they had been used.

However, the service had systems in place to safely store, administer, and record the use of medicines. There was detailed guidance specific to each person on how to administer as and when medication. We checked the quantities and stock balances for ten people and found them all to be correct. Instructions for medicines which should be given at specific times were available.