Birchmere Mews

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 remained.

Good: This meant people were safe and protected from avoidable harm.
 

This service scored 78 (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 actively listened to concerns about safety and investigated and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.
The service demonstrated a strong learning culture in relation to falls prevention and management. Leaders used a electronic RADAR system effectively to record, monitor and analyse accidents and incidents. The system's heat map function enabled the service to identify patterns and trends, including an increase in unwitnessed falls during the night and falls occurring in communal areas during transfers.
The deputy manager explained that incidents were not viewed in isolation. Instead, information was routinely analysed to understand underlying causes and identify opportunities to improve care delivery. Through trend analysis, the service recognised that many residents remained highly independent and frequently attempted to mobilise without waiting for support from staff, increasing the risk of falls.
In response to this learning, the home implemented a range of measures aimed at reducing falls while maintaining people's independence. Staffing deployment was reviewed and adapted to ensure staff were positioned more effectively during higher-risk periods and in areas where falls were occurring more frequently. The approach taken during transfers in communal areas was also reviewed and amended to provide safer support for residents.
Further oversight was introduced through regular management walkarounds, with the managers completing checks approximately every 45 minutes. This allowed for earlier identification of risks, increased monitoring of residents who may be vulnerable to falls, and provided additional opportunities to ensure staff were following agreed risk management strategies.
Where residents experienced repeated falls, the service undertook detailed multifactorial assessments to identify contributing factors and potential triggers. These assessments considered a range of factors including mobility, health conditions, medication, environmental risks, cognition, behaviours, and individual routines. Learning from these assessments informed personalised interventions tailored to the resident's specific needs.
The service demonstrated that actions following falls were individualised and proportionate to risk. Interventions included increased observations, enhanced monitoring, the use of sensor equipment, environmental adjustments and referrals to healthcare professionals such as GPs and specialist services where appropriate. These actions were clearly documented within care plans to ensure staff had clear guidance and that learning was embedded into day-to-day practice.
 

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 effective systems in place to support safe admissions, transitions and continuity of care. Staff completed comprehensive face-to-face pre-admission assessments to ensure they understood people's needs, preferences and risks before admission. Leaders reviewed all new admissions through multidisciplinary management meetings involving heads of department to determine whether the service could safely meet the person's needs and identify the most suitable living environment within the home. One relative told us, “They are really very good with medical appointments and if they feel my loved one needs another service such as GP or hospital, they are very good at pushing for them and making the arrangements my loved one is very well supported”.
Records demonstrated that admission assessments were thorough and detailed, providing staff with the information required to deliver safe, person-centred care from the outset.
Staff worked closely with health and social care professionals to share information and coordinate care throughout transitions. Care records were regularly reviewed and updated to reflect changes in people's health and wellbeing, supporting continuity of care and informed decision-making.
Staff told us they felt supported throughout the admission process and had access to the information they needed to provide safe care. Effective communication between teams and robust assessment processes helped ensure people experienced smooth transitions into the service and received care that met their individual needs.
 

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.
People told us they felt safe living at the service and spoke positively about the care and support they received. One person said, “I feel safe, 100% safe its secure here,” while another told us, “I feel safe because all staff are very nice and caring. If I had any issues I would speak to the senior”.
Staff demonstrated a good understanding of safeguarding and their responsibility to protect people from harm. They described how they would recognise and report concerns and were confident that managers would take appropriate action. Staff understood their role in advocating for people and knew how to escalate concerns, including through whistleblowing processes where necessary.
The provider had effective systems in place to identify, report, investigate and monitor safeguarding concerns. They worked proactively with external agencies, including the local authority, to ensure concerns were appropriately managed and people received the support they needed.
Appropriate arrangements were in place to support people at risk of going missing from the service. Staff used personalised risk assessments containing key information such as a person's identity, health needs, routines, significant locations, and contact details to assist emergency services if they are reported missing. The protocol was completed and regularly reviewed. Following an incident where a person left the building unexpectedly, the service reviewed the incident, implemented additional safeguards, and shared learning with staff. No further incidents had occurred following these actions.
The service worked within the principles of the Mental Capacity Act 2005 (MCA). Where people were subject to restrictions on their liberty, the provider had identified this appropriately and submitted Deprivation of Liberty Safeguards (DoLS) applications to the relevant supervisory body, helping to ensure people's rights were protected.
 

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.
People’s individual risks were clearly identified, and robust plans were in place to manage, monitor, and reduce these risks. Assessments identified emotional needs, including potential anxiety triggers, and physical health risks, such as concerns relating to skin integrity, falls, nutrition and catheter use. Staff had clear guidance on how to support people, what early warning signs to look for, and when to escalate concerns.
Staff showed a good understanding of the risks people faced and were able to explain how they supported individuals to manage these risks while still promoting choice and independence. For example, staff offered gentle reminders to use mobility equipment, enabling people to move safely around the home without restricting their freedom.
Staff consistently worked in a way which balanced risks with what mattered to people, helping them stay safe without limiting their autonomy. We saw staff supported people to spend time in the garden, walking alongside them and checking regularly the pace was comfortable. This approach ensured people remained safe while also respecting their wishes to be outdoors and maintain their preferred routines.
 

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

People lived in a welcoming and well-maintained environment and told us they liked their rooms and felt safe living at the home. The provider had systems in place to maintain the safety of the premises, including regular checks of gas, water and electrical systems. Staff addressed any maintenance issues promptly to ensure the environment remained safe for people. Family members told us the home was spotlessly clean and well maintained with no unpleasant odours. One person told us, “My loved one’s room is cleaned every day.” Another told us, “My loved one has a walker and that is always clean”.
The provider operated robust health and safety arrangements, including routine environmental audits, equipment servicing, fire safety checks, fire drills, Personal Emergency Evacuation Plans (PEEPs) and emergency grab bags. Staff maintained and cleaned equipment, including hoists and individual slings, to support safe care delivery.
During the inspection, we identified a small number of environmental concerns. The provider responded promptly and transparently, taking immediate action to mitigate risks and make the areas safe. The home was clean throughout, and leaders were enhancing oversight further through the introduction of an electronic system to support environmental auditing and monitoring. The provider demonstrated a proactive approach to maintaining a safe environment and responded effectively when issues were identified.
 

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.
People and their relatives described staff as responsive, approachable and available when needed. During the inspection, we saw staff provide timely support and engage positively with people, helping to create a calm and supportive environment. Staff told us managers maintained staffing levels that enabled them to meet people's needs safely and adjusted staffing arrangements when people's needs changed. One person told us, “The staff work together as a team really get on and that it is a good working environment”.
People and relatives expressed confidence in staff's skills and knowledge, and managers supported staff through ongoing training and development, including additional specialist training to strengthen staff's ability to support people with complex needs or health conditions.
 

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 maintained effective infection prevention and control (IPC) arrangements to help keep people safe. IPC leads took an active role in monitoring practice, promoting good standards and ensuring compliance with relevant guidance and regulations. Staff demonstrated a good understanding of IPC procedures and followed these in practice. The provider carried out regular audits, maintained a clean and well-presented environment, and ensured equipment was cleaned and monitored appropriately. Following an IPC audit undertaken by the local authority, leaders identified areas for improvement and took action to address these, demonstrating a proactive approach to reducing infection risks and promoting people's safety and wellbeing.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.
Staff managed medicines safely and effectively through robust systems for storage, administration, monitoring and auditing. They stored medicines securely, including controlled drugs and refrigerated medicines, and carried out regular temperature checks and stock monitoring to ensure medicines remained safe and effective. Staff maintained accurate records and used the electronic medicines (EMAR) system effectively to communicate changes and provide clear guidance on specific administration requirements.
Managers ensured that staff who administered medicines completed appropriate training and competency assessments. Staff demonstrated a good understanding of safe medicines management practices and followed clear procedures when administering medicines. They used PRN protocols to guide decision-making and applied additional oversight to higher-risk medicines, including patches, thickening agents and covert medicines. Staff also wore tabards during medicine rounds to minimise interruptions and reduce the risk of errors.
Staff worked with GPs to carry out regular medicine reviews and ensure people received medicines that remained appropriate to their needs. Managers completed daily, weekly and monthly audits, which enabled them to identify issues promptly and take appropriate action to maintain safe medicines management practices.