Birchmere Mews

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 remained good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 79 (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.
A positive and inclusive culture was evident throughout the service, with staff consistently describing the leadership team as approachable, supportive, and responsive. Staff felt valued and empowered to raise concerns, share ideas, and contribute to the development of the service. Regular supervisions, team meetings, daily departmental meetings, and weekly clinical risk meetings ensured effective communication, reinforced good practice, and promoted shared learning. Feedback from people, relatives, and staff was actively encouraged and used to drive improvements. The provider had embedded clear values focused on compassion, teamwork, pride, and person-centred care, which were reflected in the attitudes of staff and the culture observed during the inspection.
 

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.
Leaders were visible, approachable, and compassionate, fostering an open, inclusive, and supportive culture across the service. Leaders demonstrated a strong understanding of the service and a clear commitment to continuous improvement. Staff spoke positively about the support they received and felt confident to raise concerns and contribute ideas. Relatives described management as responsive and accessible. Regular engagement opportunities, including an open-door approach and ongoing feedback mechanisms, helped strengthen relationships, promote transparency, and ensure people, relatives, and staff felt listened to and valued.
A relative told us, “I know the manager’s they are both very lovely and welcoming, very approachable and lovely”. Another said, “The members of the senior team always say hello and very reassuring”.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
The management team promoted an open and transparent culture where staff felt able to speak up, share feedback and raise concerns without fear of blame. Managers were visible and approachable within the service, enabling people, relatives, staff and visitors to speak with them directly and contribute to the ongoing development of the service.
Managers provided a range of opportunities for staff to share feedback, seek support and discuss concerns. These included supervision sessions, team meetings, handovers, suggestion boxes and direct access to leaders. Staff could also raise concerns confidentially through the provider's HR systems and whistleblowing procedures. The provider ensured staff had easy access to policies, procedures and guidance through electronic systems.
Leaders actively sought and listened to feedback from people, relatives and staff through meetings, surveys and resident engagement forums. They used feedback to inform service improvements, including enhancing opportunities for activities and meaningful engagement. The management team responded openly and promptly to concerns and managed complaints in line with the duty of candour. This demonstrated a culture of openness, learning and continuous improvement, with a focus on achieving positive outcomes for people.
 

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.
The provider demonstrated a strong commitment to equality, diversity, and inclusion and promoted a culture where people felt respected, valued, and treated fairly. Leaders fostered an inclusive environment that recognised and celebrated individual differences, regardless of a person's background, culture, beliefs, gender, disability, age, or sexual orientation.
The workforce reflected a broad range of social, cultural, and ethnic backgrounds. Leaders valued the diverse experiences, skills, and perspectives staff brought to the service and recognised the positive impact this had on the quality of care and support provided to people living at the home.
Managers actively promoted cultural awareness and inclusion through events and celebrations that recognised different faiths, cultures, and traditions. Staff and residents took part in occasions such as Christmas, Easter, Diwali and Eid, and catering arrangements respected people's cultural preferences and dietary requirements. These celebration’s helped create opportunities for people and staff to share their experiences, learn from one another, and develop a greater sense of belonging within the service.
 

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.
Leaders maintained effective governance systems that provided strong oversight of the service and supported the delivery of safe, high-quality care. Staff understood their roles and responsibilities and worked within a clear management structure, which promoted accountability and effective decision-making across the home.
Managers used a range of robust quality assurance processes, audits, and monitoring systems to assess performance, identify areas for improvement, and drive continuous development. Governance systems operated across electronic platforms, this enabled leaders to monitor performance effectively, track actions, and share learning throughout the service. Audits routinely identified opportunities for improvement, and managers took prompt action to address issues and improve outcomes for people.
Leaders strengthened oversight through monthly governance meetings attended by departmental leads. These meetings focused on key areas including health and safety, safeguarding, clinical risks, maintenance, and people's wellbeing. This collaborative approach enabled managers to review performance, identify emerging risks, and implement timely actions to maintain high standards of care.
Managers also held daily operational meetings and weekly clinical risk meetings to review people's wellbeing, discuss concerns, and monitor changes in need. This proactive approach enabled staff to respond quickly to risks, coordinate support effectively, and ensure people received safe and responsive care.
The home benefitted from regular oversight and support from the regional management team, who provided additional expertise, challenge, and guidance to support continuous improvement and assurance of quality.
This demonstrated a commitment to accountability, continuous learning, and achieving positive outcomes for people. A healthcare professional spoke positively about the leadership within the service and described the home as well-led, with clear management arrangements and effective governance processes in place.
 

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.
Leaders developed exceptional partnerships that consistently improved outcomes for people and enriched their lives beyond their care needs. They worked proactively with GPs, community nurses, occupational therapists, speech and language therapists, mental health services, memory clinics, and falls specialists to ensure people received coordinated, responsive, and person-centred care. Strong relationships with the local medical centre enabled dedicated GP ward rounds twice weekly, allowing timely clinical reviews, continuity of care, and meaningful involvement of relatives in care discussions.
Managers worked closely with the Support to Care Home Team to identify people at risk of deterioration or frailty and secure early specialist intervention. The team also delivered specialist training and competency assessments, helping staff develop clinical skills and confidence to meet people's changing healthcare needs effectively.
The service demonstrated an outstanding commitment to community engagement. People maintained meaningful connections through regular visits to local shops, businesses, community venues, and places of worship. Leaders built innovative partnerships with local schools, offering Duke of Edinburgh placements, work experience opportunities, and careers insight sessions that enabled young people to learn about health and social care while developing positive relationships with residents.
Managers further strengthened community inclusion by inviting a local dementia day centre to use the home as a shared social space, creating opportunities for people to form friendships, reduce isolation, and remain connected to their local community. The service also worked closely with local businesses, whose donations of fresh flowers and seasonal produce enhanced activities and community celebrations.
Leaders actively contributed to the wider community through charitable initiatives. For example, seven staff members completed a sponsored climb of Mount Snowdon to raise funds for a local charity, bringing together staff, relatives, and community members in support of a shared cause. These extensive and innovative partnerships demonstrated a culture of collaboration, social responsibility, and community involvement that had a significant and positive impact on people's wellbeing, quality of life, and sense of belonging.
 

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.
When concerns arose, managers carried out thorough investigations to identify learning and implement actions that reduced the risk of similar events occurring in the future. For example, following a complaint relating to a person's fall within the home, managers completed a comprehensive review of the incident, including an examination of the circumstances surrounding the fall, risk assessments, care plans, and staffing support in place at the time. Leaders identified lessons learned and shared these with staff to strengthen practice. This included reviewing falls prevention strategies, monitoring arrangements, and communication processes to further enhance people's safety.
Managers reviewed complaints, incidents, and feedback to identify trends and opportunities for improvement. Leaders shared learning with staff through meetings, handovers, and supervision sessions, promoting reflective practice, openness, and accountability.
The provider promoted innovation and best practice through a comprehensive dementia strategy that helped staff deliver consistent, compassionate, and person-centred care. Staff had access to clear guidance on understanding people's individual needs, communication preferences, and behaviours, enabling them to promote wellbeing, independence, comfort, and reassurance for people living with dementia.