Birchmere House

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 good. At this assessment the rating has changed to 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. Staff did not always feel confident speaking up or that their views would be acted upon. Governance processes were in place but had not always identified issues found during the inspection, which meant opportunities for learning and improvement were missed.

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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Prior to the inspection, the home had experienced a few months without a registered manager. One relative told us the home felt “chaotic” during changes, describing “lots of men in suits” and saying they found this unsettling. Although they were now happy with the care their family member received, they described the new management as “remote”, saying they were visible on the floor but did not engage much with people or families. Another relative said, “It would be a nice idea if the new management would come round and introduce themselves and then we would know who they are.” Residents and relatives also recognised that the recent change in management had unsettled staff.

However, the new manager had been in post for only one day at the time of the inspection. Meetings were held later after our inspection for the manager to introduce themselves to people and relatives. The manager, whilst new in post, shared a clear vision for building a supportive culture going forward, and these plans showed promise, they had not yet had time to embed or improve consistency across the service.
 

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.

Regional leaders and local managers provided continuity in the absence of a registered manager. Staff spoke positively about the regional manager who covered during this period, describing them as “absolutely fantastic… a force,” and saying they had “a lot of respect” for their straightforward, supportive approach. A tenured manager told us, “I think all the staff are amazing. You can feel the atmosphere here… it’s vibrant. There is always so much going on!” A new manager had been appointed shortly before the inspection and set out a clear, compassionate and inclusive vision for the service. They described an open‑door policy, increased visibility through attending handovers three times a week, and plans to strengthen communication through open days, family updates and resident of the day reviews. They had introduced new resident folders containing important documentation and aimed to develop staff champions in areas such as wound care, nutrition and women’s health. The manager demonstrated an awareness that some staff may be neurodiverse and planned to introduce practical tools, such as flowcharts, to support consistent decision‑making and help build staff confidence. They also showed a strong commitment to professional accountability and development, referencing revalidation as a nurse, a diabetes diploma, leadership training, and alignment with CQC and Skills for Care registered manager frameworks. Staff told us they felt the service was “on a good path,” and recognised that leadership changes were beginning to make a positive difference. While these improvements were still embedding at the time of inspection, leadership behaviours were inclusive, values‑led and forward‑looking, helping to create a supportive culture focused on quality, competence and responsiveness.

People did not always feel they could speak up and that their voice would be heard.

Several staff told us they did not feel heard and said management did not always act on what was raised. One staff member said they “don’t feel listened to.” Another told us they avoided raising issues because “we get shot down and generally told off,” and said they were often asked to “come back later” when trying to speak with managers. Staff also described meetings where concerns were discussed but not followed up, with one person saying, “people don’t attend as they know management don’t do what is asked.” Night staff told us they rarely saw managers as they finished before management arrived, and staff felt there were very few meetings each year.

However, while some staff did not feel confident speaking up, others told us they felt able to approach the new manager and regional manager with concerns. One person said, “I am happy to speak to the manager… whatever I think, I need to come.” Staff also reported recent improvements, including more regular supervisions and meetings since the change in management, which they said had not happened consistently before. Policies to support speaking up, including whistleblowing policies, were in place and staff were aware of these.

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 the service made adjustments to support individual needs. For example, managers changed the timing of staff meetings to avoid school pick‑up times so more staff could attend. This supported staff with childcare responsibilities to participate more equally. The manager described a person‑centred approach to supporting staff, saying they aimed to “treat everyone as an individual.” They gave examples of making reasonable adjustments, such as enabling staff to take prayer breaks, supporting colleagues who were neurodiverse, and allowing the use of headphones or assistive technology where needed. This demonstrated a commitment to equity and meeting people’s differing needs.

The provider’s governance systems were not always effective in identifying or addressing concerns.

Governance processes were in place, but these did not consistently pick up the issues we found during the inspection. For example, two people had ReSPECT forms stating they were not for cardiopulmonary resuscitation (CPR), while generic choking care plans instructed staff to commence CPR. The concern here was not whether CPR would always be clinically appropriate for someone with a DNACPR or ReSPECT recommendation as in some reversible situations, such as choking, CPR may still be appropriate. However, the provider had not considered each case individually, resulting in conflicting emergency guidance across documents. This inconsistency could cause staff confusion in an emergency and represented a governance failure in ensuring personalised and aligned documentation. The provider corrected this once highlighted on inspection. Record‑keeping audits had not identified gaps in daily documentation, including incomplete records relating to people with specialist diets. Daily manager walkarounds took place but were not always used effectively to drive improvement. For example, call bell checks were completed, but response times were not consistently recorded, limiting their ability to identify delays or emerging risks. Policies were in place, but several were overdue for review. One staff member was unable to locate a requested policy during the inspection, and while staff knew ReSPECT forms were kept at the nurses’ station, not all were aware these could also be accessed electronically. Maintenance governance processes were not always clear or reliable. Records were held across paper and electronic systems, making them difficult to track. Entries in the maintenance diary often contained limited detail, with unclear descriptions that did not specify the issue, who reported it, or what action had been taken. Maintenance staff required further training to use the systems in place effectively.

However, there were elements of governance that worked well. The home had a clear audit schedule, and regular governance meetings took place, including clinical governance and health and safety meetings. Training compliance was strong in several key areas, including Equality and Diversity, Dementia, End of Life Care and Infection Control. Where safeguarding referrals and notifications to CQC had been missed by previous management, governance processes had identified this, and these were subsequently submitted by the regional team. Medication audits were carried out quarterly, and leaders understood their regulatory responsibilities.

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.

The service had strong links with the local community and actively encouraged groups to use the home’s facilities. This helped create a lively and inclusive atmosphere for people living at the service. Staff told us that community visitors brought variety and social interaction, with one person saying, “We love the community coming in… it means new people to chat with.” A wide range of community groups visited the home, reflecting diverse backgrounds and interests. For example, local volunteer groups, cultural and faith‑based communities, and animal organisations regularly came into the service, offering social events, music, and themed activities. The home also took part in community fundraising. Examples included supporting local charities, local hospitals and a youth sports team. In return, community partners sometimes shared experiences with residents to express their thanks, for example, providing a platter of foods linked to their heritage. These activities helped strengthen relationships and gave residents a sense of connection and belonging beyond the home.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Quality assurance systems were in place but had not always identified the issues we found during the inspection, meaning opportunities for learning and continuous improvement had been missed. Staff and residents told us they did not always feel their views influenced improvement. One staff member said they discussed issues in meetings, but “people don’t attend as they know management don’t do what is asked.” Others described feeling under pressure due to staffing levels and recent changes within the service, which affected morale and limited their capacity to contribute to service development.

However, staff told us they had increased access to training since the change in management, and leaders described using root cause analysis following incidents, sharing learning with staff, and taking action such as reviewing information, updating processes and notifying relevant bodies when required. Systems were in place to track learning, ensure actions remained visible and monitor progress. Meeting records showed residents were asked for feedback and that some changes had been made in response. The provider had learned from previous challenges around the rota and agency staffing, and now tried to block‑book regular agency staff to improve consistency and experience. Policies were reviewed with staff before implementation to support understanding and allow feedback. An annual survey was also used to gather people’s views, with a “you said, we did” approach to sharing outcomes. While these developments demonstrated progress, governance and engagement processes were not yet fully effective in embedding continuous learning and improvement.