Birch Park Care Home

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.

This is the first assessment for this service. This key question has been rated Good.

This meant people were safe and protected from avoidable harm.

This service scored 84 (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. Where safety concerns were identified, action had been taken, and lessons were learnt to prevent re occurrence. For example, one person was at high risk of falls and partially sighted. Following a review of their monthly falls, it was identified that a Zimmer frame in a different colour would be easier for the person to identify and use. This was supported by and implemented in conjunction with the community physiotherapist team. Once the red zimmer frame was implemented, falls were noted to have reduced. As part of the ongoing monitoring and learning, the service also signed up to the falls review programme which demonstrated their commitment to falls management and safety. As a result, staff were more vigilant around falls and were confident to implement changes and share ideas.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The provider had a strong professional working relationship with a local hospice, and many of their patients were provided with end-of-life care at Birch Park Care Home. Referrals were handled smoothly with involvement from appropriate professionals. The local hospice representative provided positive feedback on how staff worked alongside the hospice to ensure admissions were done efficiently and sensitively, working well together. The service ensured people could visit prior to their admission to support their transition into a different service and to support relatives with their loved ones’ journey. Birch Park consistently admitted people before 4pm on weekdays when health and care services were available to maintain a safe transition into the service. This approach supported the delivery of safe personalised care and supported people to have control over their needs, wishes and preferences.

Staff told us communication was very effective when people moved into the service, and documentation confirmed referral records were detailed and complete. Preadmission assessments were undertaken, and trusted assessors were utilised where the service could not attend the hospital for assessments. Information gathered transferred seamlessly into the care plan which was created with the person and their representative and was based on the initial information received. One relative told us, “I looked at a few other homes, but this was the homeliest. I came unannounced to see how they performed and had no hesitation in bringing [relative] here.”

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 they received safe care from staff, and people and relatives were aware and confident to raise concerns if they had any. Staff had received safeguarding training and were aware of their roles and responsibilities. Records demonstrated people were cared for in the least restrictive way, adhering to and promoting the principles of the Mental Capacity Act 2005.

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 and relatives told us they felt safe in the service. One person said, “I do feel safe here and the staff are always helpful and there if I need them.” Risk assessments were in place which provided good guidance to staff on how to mitigate risks to people and had been completed with people and/or their representatives. These were continually reviewed and amendments made to care practices where change was required. Accident, incident and falls were accurately reported and robustly reviewed, with clear analysis and actions taken timely following each event.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of consistently safe care. As a result, people experienced a safe and secure environment that supported their health, well-being, and independence.

Records demonstrated effective maintenance of the premises and equipment, with adherence to fire safety standards. Each person had their own personal emergency evacuation plan, and fire drills were practiced routinely. This ensured that in the event of an emergency, people could be safely evacuated, reducing the risk of harm and promoting confidence in the service’s preparedness. We observed the environment was homely, well equipped with furnishings and people’s bedrooms were personalised and designed to meet people’s needs. This contributed positively to people’s sense of identity, comfort, and emotional well-being. People told us this made them feel valued and respected.

The registered manager had considered how the environment could impact on some people’s safety in relation to their psychological, physical and sensory needs, and appropriate decisions on the layout and use of each floor was well considered. For example, dementia friendly signage was used in the service. Work on a dementia friendly garden had started. The layout of the second floor made it easier for people living with dementia to navigate and orientate themselves. People living on the nursing floor had larger rooms to ensure equipment could be used safely and offered more space and privacy to people and their families with the use of the patio doors and patio areas. These measures enhanced people's ability to move independently, reduced confusion and anxiety for people living with dementia, and promoted autonomy and dignity. Specialised equipment such as hoist, stand aids, walking aids and specialised seating was purchased for people and the service purchased equipment needed to keep people safe following assessments. This ensured that people received care and support in a manner that was safe, comfortable, and tailored to their mobility and postural needs, reducing the risk of injury and increasing comfort. People and relatives described the environment as “Cosy, warm and safe.” A relative told us, “It’s like a hotel.” These views reflected a high level of satisfaction with the living environment, which positively impacted people’s emotional well-being and sense of security.

The provider made sure there were always enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff rotas showed consistently adequate staffing levels were deployed, with different skills mix to meet people’s needs. Staff confirmed they all worked well together to provide safe care that met people’s individual needs.

Recruitment processes were safe and robust, and staff received sufficient training and development in the areas they required. Kitchen staff completed International Dysphagia Diet Standardisation Initiative (IDSSI) training which had enabled them to learn from a qualified trainer new way of cooking and presenting food for those with specialised diets, such as pureed food. The kitchen staff developed new skills which has been well received by people and their relatives. All people and relatives we spoke to were happy with the number of staff present, and they told us they felt the home had enough suitably trained staff to meet their needs.

The provider assessed and managed the risk of infection. They quickly detected and controlled the risk of it spreading and shared concerns with appropriate agencies. Domestic staff followed robust cleaning schedules and maintained the home to a good standard showing compliance with the homes infection prevention and control (IPC) policy.

Staff wore personal protective equipment correctly and at the appropriate times, and handwashing facilities were available throughout the home. Leaders monitored the cleanliness in the home to ensure IPC processes were continually effective. Leaders knew what to do in the event of an outbreak and they demonstrated they had good knowledge of the national guidance.

People and relatives spoke positively about the cleanliness of the service. One relative told us, “It’s very clean and there are never any smells here, unlike in some places” and “The staff keep on top of [relatives] personal hygiene and the home is always spotlessly clean.” We observed a clean and well-maintained environment for people. This feedback reflected the positive impact on people’s comfort, dignity, and overall experience of care, reinforcing their sense of being well cared for in a clean and respectful environment.

We found the provider did not always ensure records linked to people’s medicines were completed as appropriate, but we found no evidence of this having a negative impact on the care people received. Documentation in the medication administration records (MARs) was not always consistently completed, with no explanation for the gaps in the records. Topical cream records were not always completed despite staff having body maps to show where the creams needed to be applied, however we found there had been no detrimental impacts on people’s skin integrity. People that were prescribed ‘as and when’ required medication (PRN) did not always have an up-to-date protocol in place to ensure knew when to give these medications. However, staff were able to describe how and when they would support people with these medicines. The service was monitoring the temperature of the treatment rooms where medication was being stored, including fridges. Storage of medication and controlled drugs was safe and checked were being carried out routinely.

We did not find any evidence of harm to people, and we were assured people received their medication when they required, and that these were administered safely. The registered manager responded immediately to the feedback regarding the management of medicines and action was taken during our assessment to rectify some of the shortfalls with clear learning evidenced from the feedback.