Birkdale Court

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 requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 61 (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 have a clear shared vision, strategy, and culture. They did not always understand the challenges and the needs of people and their communities.

We did not identify any concerns regarding the caring interactions between staff and people using the service. However, weaknesses in governance and oversight limited the provider’s ability to demonstrate consistency in care, and a clear, shared vision and culture, including how learning, feedback and improvements were embedded within the service.

Not all leaders understood the context in which the provider delivered care, treatment, and support. Staff and relatives were positive about the registered manager and the staff team. The registered manager was visible within the service and involved in the day‑to‑day running of the home. However, leaders did not always demonstrate a sufficient understanding of the context in which care, treatment and support were being delivered. Whilst there was a registered manager and management structure in place, we found significant gaps in leadership oversight. A number of risks to people's health, safety and wellbeing had not been identified, assessed or managed effectively through existing monitoring arrangements.

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. Relatives and professionals shared positive feedback about the service. A relative said “The management team are approachable, and they listen and engage with us.” Staff were able to tell us how they would escalate concerns for people within the organisation and with the involvement of other agencies if required.

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 promoted equality and diversity within the workforce and ensured staff were treated fairly and with respect. Staff spoke positively about how they were supported in their roles and felt their individual diverse needs were supported. Staff shared with us how the registered manager had supported them in their individual circumstances and provided support in both their personal and professional lives.

Governance and oversight systems had not identified and addressed risks to people's safety and wellbeing. Despite regular audits and monitoring, the provider had not identified the concerns found during this assessment, demonstrating a lack of effective oversight.

Care records were not always accurate, completed fully, or consistent. Care plans contained conflicting information and health monitoring recorded within care plans was not consistently reflected in daily records. This increased the risk of staff making decisions based on inaccurate information and people not receiving care that reflected their current needs.

Medicines governance was not sufficiently robust. Audits had not identified handwritten entries on medicine charts were not always verified by two staff members to confirm accurate transcription. In addition, body maps were not available to direct staff where prescribed creams and ointments should be applied, creating a risk of inconsistent administration and reducing assurance that people received their medicines as intended.

Oversight of the MCA was also ineffective. Not all people had mental capacity assessments or best interest decisions in place where required. Where assessments had been completed, the information recorded was inconsistent, including differing diagnoses documented for the same person. This meant the provider could not demonstrate decisions were being made in accordance with legal requirements and people's rights were protected. The absence of consistent MCA documentation evidenced a lack of monitoring and scrutiny of this process.

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. Health professionals reported that the service was improving, with the manager implementing positive changes that supported better health outcomes for people. One health professional said, “Management and the staff team are approachable; they are supportive and listen to any advice that is given.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Although improvements were in progress, at this assessment we found breaches of regulations. Systems and processes needed to improve and monitor the service were not fully effective. Further work was needed to ensure risk was identified and then appropriate action taken. However, feedback indicated the home manager was open and responsive, and that the provider had implemented improvements to aspects of the service.