Birch Hall Care Centre

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 inadequate. At this assessment the rating has changed to requires improvement. This meant the service 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 good governance.

This service scored 62 (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 feedback from people, relatives and the staff team about the management was mixed with some demonstrating confidence in the management but others raised concerns about the recent changes. One staff member told us, “There is a good culture here, but I don’t think the changes were communicated well.” Feedback was obtained from people, relatives and staff. The management told us these were being completed electronically. More recently evidence of positive feedback was seen in some, but where some concerns had been raised the records did not identify what actions the management had taken as a result. The provider had undertaken a review of people’s views with regard to the changes to the environment recently and how this was impacting people whilst this was ongoing.

Management changes had taken place recently the manager was new; the senior team was positive about the recruitment of the new manager and the challenges they faced to make improvements in the service. The manager demonstrated their commitments to make improvements in the service and had commenced the process of applying to be registered manager we received confirmation during the assessment process they had been successfully registered as registered manager.

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.

All of the staff who provided feedback were positive about the management and their support. The management discussed what actions they had taken to address shortfalls in the service and staffing concerns. They talked about how they encouraged open dialogue with the staff team and obtaining feedback from them. We received positive feedback about the manager and the support and improvements in the service recently but that the communication about this could have been managed better. However, some feedback in relation to other members of the management team was mixed. All members of the management team were visible and based in the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were confident with the management and that they would be able to raise concerns with them. Comments included, “I feel comfortable raising concerns if needed and believe management listens to staff” and, “I understand freedom to speak up and feel able to raise concerns without fear.”

Regular meetings with staff, management and people were being undertaken with records confirming the topics discussed and where concerns had been raised. Staff told us team meetings were taking place. They said, “We have staff meetings and opportunities to give feedback” and, “Staff meetings and feedback opportunities allow everyone to contribute.” Records of daily departmental meetings and clinical meetings were noted.

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.

Staff told us they felt included, treated fairly and the management were kind. Comments included, “I feel treated fairly and have completed equality, diversity and inclusion training” and, “Personal beliefs are respected, manager treats all staff well and fairly.” Information in staff files in relation to job descriptions to support and protect staff rights was seen and a range of information and guidance was available to support staff in delivering care and support to people.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Audits and monitoring was taking place in some areas but the records we reviewed did not always demonstrate what action had been taken as a result of these or if they had been followed up and these failed to identify the concerns we found at this assessment. The provider had completed a detailed audit recently, but this failed to identify the concerns we found at this assessment. Concerns were identified at this assessment in relation to the safe management of individual and environmental risks, safe infection prevention and control practices, providing good care, ensuring care records were detailed in place and up to date to support their care and good governance systems.

People were positive about the improvements since the manager came to post. One said, “There's been a real positive impact since [registered manager] has been in position. She will walk the floor she comes out she doesn't hide.” Some staff were positive about the management. One staff member told us, “The manager is really good and helps out when she can. The manager is determined in her work.” However, another staff member talked about occasions where a concerns had been raised in relation to their day to day role with the management, but no changes had taken place.

All levels of the management team were visible in the service, and the nominated individual was based at Birch Hall Care Centre providing senior oversight and support as needed. The management team discussed the actions they had taken including the recruitment of new management prior to our assessment.It was apparent people, relatives and staff knew all levels of the management team. The manager was visiting the service regularly during out of hours, records detailed their findings to recognise good practice and areas of improvement if required. The new management had improved the documentation to ensure all people were reviewed as part of the resident of the day system.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.Whilst we saw evidence of community participation this could be better and 1 person fedback their difficulties accessing the community as they chose. The manager provided feedback about how they would ensure people’s choices and preferences are supported that supported right support, right care, right culture.

Professionals and partners were visiting the service and evidence of their involvement was noted and staff confirmed this. One staff member told us, “People are encouraged to access community activities, groups and appointments where appropriate.

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.

Staff told us they undertook training to support them in their role. Managers said training was ongoing. The manager told us, “All of the staff have had the same training.” The names of champions and the roles they undertook was on display to inform people and visitors of the enhanced roles of the staff team. one staff member told us, they had just commenced in a champions role and they were, “Not sure what role entails as only just started.”

The provider told us they were in the progress of making improvements in the service, we saw this was ongoing at the assessment. A refurbishment plan had been developed, and the provider was working to ensure the planned improvements were ongoing. We discussed with the senior management the importance of ensuring dates for action plan completion on work are reviewed with revised dates as required. Records demonstrated a system was in place for lessons learned and how these were shared with the staff team.

Certificates of registration and the ratings from the last assessment were on display and the service was submitting statutory notifications in line with their statutory duties. Information was being stored safely in locked offices and electronic devices were password protected this would ensure they met GDPR (General Data Protection Regulation) requirements.