Birchwood

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 inadequate. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Systems were in place to promote learning from accidents, incidents, complaints and safeguarding’s. The provider had a lesson learnt policy and procedure in place which outlined staff’s key responsibilities in relation to the implementation of the policy. These provided guidance for staff on the importance of learning from incidents and the systems in place to record those. Lessons learnt was a regular topic in the staff meeting and the minutes of the meetings showed discussions and actions to mitigate the risk of reoccurrence.

Staff told us learning from incidents were discussed in team meetings and handovers. A staff member commented, “When things go wrong, we find the root cause, why it occurred, why it should not happen again with measures put in place to prevent it”.

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.

The service had secured the services of a Speech and Language Therapist (SaLT) who work closely with the service in assessing and reviewing people’s communication and swallowing disorders. They provided the service with comprehensive reports on communication and eating and drinking needs which were incorporated into people’s care plans to promote safe care. SaLT made referrals to other professionals such as dieticians when required for people.

People had a hospital passport in place, which were kept up to date and formed part of a structured emergency hospital information pack which included individual communication and swallowing needs. These were accessible to staff in an emergency. The SaLT staff member liaised with the hospital when a person from the service was admitted there to ensure they had access to the emergency hospital packs so people’s communication and dysphagia needs were known. This promoted a safe transition from the service to hospital.

A person’s discharge from the hospital was managed in a coordinated and integrated way to ensure their ongoing health needs were fully understood and safely supported. The providers clinical lead reviewed the discharge information, including the person’s additional health needs and infection status to provide assurance and guide safe continuity of care. The service worked collaboratively with the hospital team throughout the person’s admission, including supporting the person with eating to maintain consistency in their care routines. Alongside this, the service liaised with the Local Authority to request a review in response to the person’s changing needs. An emergency multidisciplinary meeting was arranged, and additional support was agreed to ensure the person’s care package remained appropriate. This joined‑up approach supported a seamless transition from hospital and ensured clear communication between professionals and continuity of care for the individual.

Staff supported people to appointments with records maintained of the outcome and follow up. Staff maintained regular contact and visits to people when admitted to hospital to provide reassurance, support and promote safe systems. Relatives told us they were informed if their family member was unwell. They confirmed staff always assisted their family members to appointments and they had regular reviews by the GP.

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.

The service had policies and procedures in place to safeguard people from abuse. Staff were trained in safeguarding with posters displayed to remind them of the process for reporting. Incidents of potential abuse were reported to the relevant agencies in line with safeguarding procedures.

People were provided with information on abuse in an easy read format to enable them to have the information to act to safeguard themselves.

People told us they felt safe living at the service. A person commented, “I definitely feel safe here. I can talk to staff if I have any problems”. Relatives told us their family members were safe. Relatives commented, [Family member’s name] has a better quality of life, they are safe and their needs are met whilst having made new friends and connections”.

We checked whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. We found systems were in place to monitor legal authorisations and renewals were completed when required.

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 provider had appropriate systems in place to identify, assess and mitigate risks to people’s health, safety and welfare. People who required them, had positive behaviour care plans in place and risks associated with conditions such as diabetes, epilepsy, choking and falls were clearly identified and effectively managed. Risk assessments were person centred, regularly reviewed and reflected people’s current needs whilst promoting their independence.

Staff demonstrated a good understanding of people’s needs and risks to promote their safety. During the inspection, we observed staff providing support in line with people’s risk assessments, including providing appropriate supervision and support at mealtimes for people at risk of choking which helped keep people safe.

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

Since the previous inspection the service had been refurbished throughout, and the environment was bright, homely and welcoming. There was a refurbishment plan in place to ensure the ongoing upkeep and maintenance of the service.

Risk assessments were in place for all relevant areas of the service and were reviewed annually, or sooner where required to ensure they reflected current risks.

The provider held up‑to‑date certificates for key safety systems, including gas safety, fixed electrical wiring, fire safety systems such as emergency lighting, alarms and extinguisher servicing, portable appliance testing (PAT), legionella testing and Lifting Operations and Lifting Equipment Regulations (LOLER) inspections for hoists and beds

Records showed the local fire service had carried out an inspection, and the provider had acted on and completed all recommendations.

A designated health and safety champion was responsible for carrying out routine health and safety checks, including weekly and monthly fire alarm checks, fire door inspections, water temperature monitoring, oxygen equipment and storage oversight, and checks on wheelchairs and bed rail gaps. Records showed these were consistently completed with no gaps identified.

First aid boxes were located throughout the service and were well stocked with items in date. These were subject to regular checks and audits.

The registered manager and provider were responsive and supportive to equipment needs and acted promptly when staff identified the need for new or replacement equipment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were suitably inducted, trained, supervised and supported to carry out their roles safely and effectively. Records showed new staff received an induction and workbooks were signed off to demonstrate their competencies and completion of their induction. All staff had regular access to training the provider considered mandatory for the service and specialist training, to support them to have the skills and knowledge to meet people’s needs. The service had designated ‘train-the-trainer’ staff in key areas including enteral nutrition and hydration and moving and handling which supported safe and consistent practice. Staff competency assessments were completed in relation to medicine management, enteral nutrition, moving and handling and hand hygiene which provided assurance of staff competence.

Relatives told us staff seemed suitably trained and that a number of staff had worked there for a long time, which provided continuity of care. A relative commented, “Yes, on the whole staff are competent, especially now they are doing more training than previously. It has been the same staff for many years. They know [family member’s name] well. I would say some of the staff know what [family member’s name] is thinking even if they cannot say”.

The provider used a dependency tool to determine the number of staff required to meet people’s needs safely. Staffing rotas showed the identified staffing levels were generally maintained, which helped to ensure people received the support they required. However, the rotas showed that on occasions some staff worked a number of consecutive days in a row. This was fed back to the registered manager who provided evidence that this had been identified and addressed by them with systems around rota management improved to prevent a reoccurrence.

Recruitment files contained all required checks, such as a check for criminal convictions and uptake of references.

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 service was clean, hygienic with systems in place to maintain a high standard of cleaning. The service had a cleaner. They had a cleaning schedule in place which outlined the areas to be cleaned daily. These were signed off when completed. Day and night staff had responsibility for cleaning tasks when the cleaner was not on duty, and they supported people with their bedroom cleans.

Staff were trained in infection control, and policies were in place to guide their practices. Infection control procedures were regularly audited to ensure compliance. The service had a named staff member as an infection control champion who had responsibility for the oversight of infection control. Personal protective equipment (PPE) was readily available to staff whenever needed for personal care tasks. We saw staff wore aprons and gloves when supporting people with meals. These were disposed of appropriately.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Record keeping must be improved to ensure they accurately reflect people’s treatments.

People mostly received medicines safely and as intended by the prescriber. When looking at medicines administration records (MARs), we found one instance where an acute antibiotic was still listed on the MAR and marked as being administered despite the course being completed a number of days previously.

The medicines fridge was monitored daily. However, temperatures exceeded the recommended range on multiple occasions. Staff did not follow protocol which was attached to the fridge advising them to alert the management team if the fridge temperature was out of range. This could affect the integrity of the medicines stored inside the fridge and therefore make medicines and treatment ineffective. The registered manager took immediate actions to replace the fridge and reminded staff of the importance of escalating to them if the fridge temperatures are out of range.

Medicines were stored in individual locked cupboards, with excess medicines stored in a separate stock room. One person’s painkiller medicine was missing from the cupboard. When we highlighted this, we were told it was accidentally discarded by staff. Therefore, the person would not have been able to access their medicine if they needed it that day. Another person’s mouth gel was on the MAR chart, but the medicine was not kept by the provider. Staff told us the gel was not stopped by the GP, and they would query it.

Whilst medicines were audited there was no system to audit who had responsibility on each shift for the medicine room’s key. The registered manager agreed to address that to further promote safe medicines.

Guidance was in place to support ‘when required’ (PRN) medicines. Care plans had the necessary information to support people with their health needs and prescribed medicines. The service largely identified medicines with additional risks that should be managed and monitored.

Staff were trained and deemed competent to administer medicines. Some staff received additional training on administering medicines via a balloon gastronomy tube (a tube that allows them to administer food or medicine directly into the stomach if a person is unable to have this by mouth) and there were clear provisions in place to contact nursing staff if required.