Birchmere House

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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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.

People were not consistently kept safe due to delays in responding to call bells. Although staffing levels often met planned numbers, a high reliance on agency staff who did not always know people well affected the quality of care, particularly at night. Some risk assessments also lacked the level of detail needed to guide safe and personalised support.

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

This service scored 56 (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 promoted a proactive and positive culture of safety, where openness and honesty were central to how concerns were managed. Staff listened to people’s views, responded to safety issues, and used learning from incidents to improve practice.

The service investigated concerns thoroughly, followed relevant policies, and took action to prevent similar issues from happening again. Residents told us they felt comfortable raising concerns. One resident said, “If I did have a complaint, I would tell a member of staff.”

Staff were confident in the steps they should take when responding to accidents and incidents. They described calling for an ambulance when required, completing observations, informing the nurse and the person’s family, and documenting the incident on the electronic system. This system recorded what happened, the actions taken, and any follow‑up needed. Where patterns emerged, incidents could be linked together to support wider learning. Actions were added to an overarching action plan, and staff could record any lessons learnt. Examples of action taken from learning included reviewing equipment, seeking advice from the GP or falls team, and updating care plans and risk assessments. These actions showed that learning was embedded in everyday practice.

The provider did not always establish or maintain safe systems of care. They did not consistently manage or monitor risks to people’s safety, particularly in relation to call bell responses.

Significant concerns were identified about delayed call bell responses and staffing levels, particularly at night. People, relatives and staff consistently told us they experienced long waits for support. One resident said, “Sometimes they don’t come for an hour,” and another shared, “Recently they’ve not been coming… I dread the evenings waiting”. Relatives also raised similar concerns with one saying, “Call bell times are not the best.” During the first day of inspection, call-bells were observed to be sounding for long periods without a prompt response. Although the provider identified a technical fault with the system and sought technical support a few weeks prior to our inspection of the service, on inspection we found significant delays in response times which highlighted to the provider that this fault was still not resolved. People, staff and relatives felt delays were also linked to staffing capacity. One staff member said, “We are delayed getting to people,” and another told us, “We are really understaffed”. Records showed 2 occasions where a resident’s call bell had been removed or placed out of reach due to repeated use, which created further concerns about access to timely support, however the provider had identified this through internal checks and had taken action to address this. The provider took some immediate action following inspection feedback, including placing an additional staff member on shift to monitor call bells and resolving the signalling issue. Meeting records showed that staff had been reminded of the expected 2–5 minute response time, and the importance of responding promptly. Call bell analysis was also expected to be completed weekly and reviewed through governance meetings to monitor improvement. However, time will be needed for these actions to be fully embedded to address the ongoing risks to people’s safety.

People also shared that they experienced positive support when moving into the home. One resident told us, “We came to see the place before we moved in… When we arrived, we had a welcome card and flowers.” Staff visited people in hospital or at home before admission and provided clear information about the service before completing an assessment of their needs. Reassessments were completed when someone had been in hospital for more than five days, and staff worked hard to make transitions smooth, including signposting to relevant support services. When someone moved into the home, an initial assessment was completed on admission and further reviewed over the following five days, allowing staff to fully understand and respond to each person’s needs.

The provider did not always ensure people were protected from the risk of harm. While safeguarding processes were in place and managers understood their responsibilities, not all staff had the knowledge or awareness needed to consistently recognise or respond to safeguarding concerns.

Most residents told us they generally felt safe living at the service; however, many said delays in staff responding to call bells sometimes made them feel unsafe. One person said, “The waiting… the waiting makes me feel unsafe,” and another told us they did not always recognise staff at night, which they found “particularly scary.” Several residents also said that overnight staff were not visible, and when they left their room to seek help, they were unable to find anyone. However, since our inspection, the provider has completed further reviews of resident’s experience at the home and have shared documentation which detailed positive experiences. Such as, one person said they “like living at the home” and another shared that they were “happy with the care” they receive.

Not all staff showed a strong understanding of safeguarding or the Mental Capacity Act (MCA). Training completion for safeguarding was at 90% at the time of inspection, which required improvement. However, some staff were able to describe what they would do if they witnessed poor practice which included reporting concerns to the manager or deputy. Not all staff understood the MCA, one staff member shared they thought the MCA was about “residents or the government… that if the resident has some challenges you have to know their area to work with them”. However, one staff member said, “If they lack capacity, I involve a family member or the GP… I still ask the resident what they want, even if they can’t answer,” showing an awareness of involving people as much as possible. Another described offering limited choices so as not to overwhelm someone and explained how they would encourage a person to wear warm clothing by talking to them and offering reassurance. While these examples showed pockets of good practice, overall understanding was inconsistent across the team.

However, managers demonstrated a clear understanding of safeguarding procedures and were able to talk through their processes confidently. They showed us their safeguarding log, and the operations director shared that they reviewed incidents monthly to identify any themes and allocate follow‑up actions where required. Managers also understood Deprivation of Liberty Safeguards (DoLS), tracked authorisations effectively and were aware of any conditions in place. DoLS processes were well managed, with clear systems in place to ensure authorisations and conditions were monitored.

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 for people, but they were not always robust or detailed enough to guide safe and personalised care. For example, guidance about the safe use of emollient creams was inconsistent, and some assessments lacked clear instructions on how staff should support people safely. In one care plan, a person was described as unable to weight‑bear and requiring specific equipment and slings, but there was no information about the correct routine for transferring them, or the consideration of additional risks linked to their Parkinson’s diagnosis and anticoagulant medication. This meant staff did not always have the information they needed to keep people safe.

People also told us that the support they received varied depending on which staff were on duty. One resident said, “Some of the staff are more aware of what I need than others,” reflecting inconsistencies in staff knowledge and practice.

Staff described pressures that made it difficult to keep up to date with people’s care plans. One member of staff explained, “We don’t always have time to read the care plan,” and another said, “Some people don’t want agency staff, so we’re stretched and can’t focus on the care plan.” These pressures increased the risk of staff relying on habit or verbal handovers rather than the written guidance in people’s care records. As a result, people were not always supported in a way that fully considered their individual risks or promoted their independence and wellbeing.

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 environment was clean, warm and welcoming, and staff had access to equipment that was regularly serviced and well maintained. Window restrictors were in good repair, and fire doors across all floors were functioning correctly and routinely checked. Fire safety arrangements were well established, with regular fire drills taking place at different times of day, including evenings to involve night staff. A personal emergency evacuation plan (PEEP) folder was available in reception and included contingency information, next‑of‑kin details and isolation points. Fire safety was also discussed with residents in meetings, giving people an opportunity to understand how the home stays “fire safe” and what would happen in an emergency. Families were welcomed to join these discussions. Staff were confident in describing the fire procedures. One member of staff explained that during a drill, “Two people go to the main panel and three go to the zone with walkie‑talkies… we sign a sheet to say we attended and check all doors to reassure residents.” They also described how, in a real fire, staff would prioritise calling emergency services and supporting residents to evacuate safely, guided by fire safety leaders and the information in people’s care plans.

While the overall environment was safe and well maintained, there were some areas requiring improvement. Occasional obstructions, such as a hoist or cleaning equipment left in corridors, created potential trip hazards. Some slings were incorrectly labelled, which increased the risk of inappropriate use.

Although people spoke positively about the responsiveness of maintenance staff, the provider’s maintenance records did not clearly demonstrate what actions were identified, completed or signed off. The fire risk assessment was in place but did not always verify that required actions had been completed. Training compliance for fire safety and fire drills also required improvement at the time of inspection. However, the provider showed swift progress, with fire safety and evacuation training increasing from 89% to 95% and fire drill compliance improving from 90% to 91% within one month.

The provider did not always ensure there were enough skilled and competent staff to meet people’s needs safely. Although staffing levels appeared adequate on rotas, people’s experiences, high reliance on agency staff and gaps in staff support and oversight meant care was not always consistent, safe or effective.

Significant concerns were raised about the high use of agency staff and the impact this had on people’s care. People who lived at the service described feeling unsettled by unfamiliar staff, particularly at night. One person said, “It’s particularly at night that there seems to be a shortage of staff,” and a relative shared, “The agency staff aren’t as good as the people who know my loved one.” Permanent staff felt under pressure when many agency staff were on shift. One staff member said, “Permanent staff have to do more… the job is double for us,” and another told us, “Some agency don’t know how to use a hoist… this is a risk.” Visiting professionals also noted nurses were frequently interrupted due to high demand.

Agency staff completed an induction checklist, which included key processes and systems training, but permanent staff reported they still needed to double‑check their work. One staff member said, “We need to follow them to make sure the job is done correctly.” During the inspection, an agency worker asked an inspector where to put a dirty mug, showing uncertainty about daily routines. People’s experiences suggested staffing levels were not always sufficient, despite rotas showing required numbers were met.

Concerns were raised about skill mix and leadership overnight. People told us, “There are no senior people on at night,” and, “The night staff are nowhere near as good as the daytime staff.” Some residents described limited opportunities for personal care, such as showers, due to staffing pressures.

Recruitment systems were mostly robust, including sponsorship licence checks, but some workforce records contained gaps. Two staff references lacked verification, and one person’s employment history showed unexplained breaks. Staff support was inconsistent. Supervisions were not held in line with the provider’s two‑monthly policy, with some staff having several recorded and others only one. Staff described supervisions as being “told off,” and records did not show two‑way discussion. Annual appraisals and personal development plans (PDPs) were not consistently completed or updated.

However, training compliance was generally good but required improvement in key areas. Duty of Candour, medication competency, basic life support and moving and handling training required strengthening to ensure all relevant staff were confident and competent in these aspects of care. Staff views on induction varied: one person felt “thrown in the deep end,” while others described two weeks of shadowing and felt prepared to carry out their role. Although concerns were raised about agency practice, one agency worker reported their induction was useful and they knew who to seek guidance from. Residents generally felt staff were well trained, and nursing staff reported regular clinical supervision. Staff valued practical sessions such as International Dysphagia Diet Standardisation Initiative (IDDSI), which described the different levels and definitions of food and fluids. Families were also encouraged to attend this training. The new manager acknowledged staffing pressures and outlined plans to improve recruitment, reduce agency use, strengthen night‑time oversight and complete more regular supervisions and spot checks.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

During medication rounds, inconsistent hand hygiene was observed, increasing the risk of cross‑contamination. Some hand sanitiser dispensers were empty around the home, indicating gaps in environmental checks. In the sluice room, soiled waste bags were found tied and left on the floor rather than stored appropriately, which did not follow safe clinical waste management. Inspectors also found two out‑of‑date milk products, showing food hygiene monitoring required improvement.

Despite these issues, the environment was clean, tidy and well maintained, with good routines in place to keep standards high. Residents told us they felt the home was clean, and relatives described rooms as “spotless and perfect.” Laundry areas were observed to be tidy and well organised with clear processes in place. Staff had access to appropriate personal protective equipment (PPE) and were clear on when and how to use it. One staff member told us, “We use PPE every time we do personal care — masks, gloves, aprons — washing hands before and after and disposing of things correctly.” Staff were also confident describing barrier‑nursing processes when required.

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

Inconsistencies in medicines records and practice meant people were not always fully protected from risk. Electronic medication administration records, (eMARs) contained inaccuracies, including an entry error where a medicine appeared with multiple administration times exceeding the prescribed frequency, and another instance where a medicine was scheduled four times daily rather than once at night as prescribed. While there was no evidence that medicines were administered incorrectly, these errors in how medicines were entered onto the system increased the potential for mistakes. Inaccurate MAR entries can lead staff to administer medicines at the wrong dose or time, creating a direct risk of harm. People’s experiences also indicated inconsistency in administration. One resident told us their medicines were “done correctly most of the time” but were sometimes late, which they found difficult due to their Parkinson’s. Another said they did not always receive their eye drops every two hours as required and that they “dread the evenings waiting” for medicines. A further resident said, “If I could change anything, it would be that they improve my medication timings.” It was reported that staff normally observed people taking medicines, but on occasion tablets were left with the person.

However, on review of records, medicines were administered at the right time with the exception of one documented occasion where a dose was given an hour later because the person was too sleepy to take it safely. The provider has since shared an updated MAR showing that the previously identified upload inaccuracies had been corrected. The medicines trolley displayed a “do not disturb” sign and was locked and secured when unattended. Fridge temperatures were checked day and night; the fridge was locked and correctly labelled. First aid kits were in place. Controlled drugs (CDs) were well managed, with records detailing orders, drug names and individuals’ details; stock balances matched the CD register. Two registered nurses were present for CD destruction using a denaturing kit, and no discrepancies were identified. Thickener products were stored securely. Medication reviews were carried out annually but sometimes sooner if people’s needs changed. Staff were able to describe the steps they would take if a person refused medication, including offering encouragement, contacting the GP, exploring alternatives and informing family members. This reflected a good understanding of procedure and escalation.