Silver Birch Care Home

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 Requires Improvement. At this assessment the rating has remained Requires Improvement. This meant management and leadership was not always consistent. 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 of the service. This meant thatsystems to oversee the safety of people’s home environment were not robust and failed to identify risks we found during our assessment.

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 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.

Staff we spoke with had a shared passion for the service and care for the people living there. Staff told us they had worked there many years and were happy in their role and felt supported by both the registered manager and the owner.

The registered manager demonstrated a caring attitude and knowledge of the people using the service. Everyone spoke about teamwork and were supportive of everyone’s roles within the home.

There was evidence of a culture where feedback was sought from people, relatives, staff and visiting professionals. We saw the values of the home were displayed for all to access.

During our assessment we identified significant risks in the environment which could have caused harm to people living at the service. The systems the provider had in place to audit safety had not identified these, which meant that there was a need for areas for development including improved oversight of risk. The management team responded positively and made changes during our assessment.
The home was managed by a registered manager with experience in this care setting. The registered manager was clear about their role and responsibilities.

Staff spoke positively about the management team. They felt well supported and confident in their job roles. Staff told us the management team was approachable and knowledgeable. The management team was supported by the provider who visited the home on a regular basis.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they were able to speak up confidently and the manager proactively encouraged people to raise any concerns. The management team ensured staff could contact them to speak up. A staff member told us, “The manager and owner are really supportive, any issue we can go to them straight away and tell them, they always listen and follow things up.” The provider’s policies were clear for staff to follow and speak up if they had concerns. We saw evidence that policy and best practice was shared in staff supervisions and staff meetings.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff were supported and encouraged to develop, with many staff progressing into more senior roles. Staff told us they felt well supported by management who were keen to ensure they had a good work-life balance, which also offered care and flexibility when health or family circumstances required it. Staff felt well supported in doing their jobs and spoke positively about teamwork, shared values and care for people.

The service 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

The provider did not have clear understanding of their responsibilities relating to health and safety in the environment. There was a lack of systems and did not always act on the best information about risk, performance and outcomes.

At our last inspection, the service was in breach of the legal regulation related to governance. The service remains in breach of the regulation. The service did not operate effective systems to always ensure the safety of the environment. They had not identified risks relating to window restrictors not being in place, access to restricted areas and incorrect storage of hand sanitiser. Systems were therefore not robust enough to demonstrate good governance. This placed people at risk of harm.

We shared all of these concerns with the management team who took immediate action to address these risks.

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.

Staff followed clear and effective systems and processes which demonstrated effective partnership working within the service's staff team, as well as with external professionals and partners. A health professional told us, “The staff are really approachable, the staff are caring we’ve not had any problems with this care home. The management are good.”

Another told us “The residents are looked after. We’ve not had any concerns about any of the patients in our care.”

We saw evidence that a multi disciplined approach was taken when people came to the service or there was a change in their needs.

Whilst the provider was focused on continuous learning, innovation and improvement across the organisation and local system, the changes they had made required further embedding to ensure improvements were sustained.

The provider was committed to continuous learning, innovation and improvement across the service. We saw processes in place where findings from audits, meetings and feedback received was recorded and analysed by the manager. Although the provider had systems and processes in place to identify actions to drive improvement, they were not always effective. For example, some audits lacked detail such as the environment audits and therefore failed to identify key risks and drive improvement.

We observed the morning handover meeting, where important information was shared in respect of people’s health and wellbeing. There were regular staff meetings, and the minutes of these meetings demonstrated lessons learnt. The staff team then had the opportunity to make suggestions and feedback their experiences. We saw when incidents or accidents had occurred such as an increase to falls, the manager had arranged specific learning to understand the cause and what could be done differently to make improvements within the service.