Birch Park 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.

This is the first assessment for this service. This key question has been rated Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

[LH1]agree

This service scored 86 (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 demonstrated the values of the service and understood the requirements and how this applied to their role. Staff felt there was a culture of collaboration, led by the registered manager and other leaders in the service. One staff member told us, “Both the deputy and registered manager are ready to support and guide at any point. They hold the home together. We are told we are not just satisfying 1 person; we are satisfying residents and their families.”

The provider had exceptionally 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. They understood the positive impact this had on people’s experience of living at the service. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

All staff told us they thought the registered manager led by example and was visible in the service. This supported a positive culture. Staff felt leaders had all the required skills, knowledge and experience to lead effectively which supported them to deliver exceptional care. Staff provided examples of when the registered manager (registered nurse by profession), had come into work over evenings and weekends to support nursing staff with people who had high nursing needs to ensure they received the best possible care and to support staff during difficult times. This meant staff were able to be focused on meeting all of the person’s needs. The registered manager worked alongside other professionals, particularly with the local hospice staff supporting end of life care to ensure it was of the highest standard in people’s preferred place of care. Other members of the leadership team held specialised licenced abilities, such as the deputy manager being a licensed Lay Minister authorised by the Bishop. The deputy manager had by request of people in the service, practiced their role and held prayers with people and families, and had contacts relied upon throughout the Diocese in which they ensured people had their last rights read for those that had requested this. Both leaders were described by staff as being hands on and passionate about delivering high quality of care.

Systems and processes were in place which demonstrated leaders had received training and development for their roles, and spot checks and compliance audits confirmed the quality of care was being continually reviewed and analysed. Where things had gone wrong leaders had acted with honesty and integrity, applying their duty of candour as and when required. The manager is registered with CQC and has been registered manager in the service for multiple years, showing consistency in leadership.

People and relatives spoke positively about the registered manager. One relative told us, “The [registered] manager is lovely. They always make time for me and is available anytime. I feel they have gotten to know [relative] and their little ways. I have no complaints. I wouldn’t want [relative] anywhere else; you can’t buy peace of mind.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were aware of freedom to speak up and felt they would be listened to. Where lessons had been learnt this had been shared and effectively communicated to all staff timely. Whistleblowing policies and complaints procedures were in place and provided staff with guidance in line with best practice on speaking up.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them. Staff told us they felt valued and where appropriate could give examples of adjustments made to accommodate their needs and circumstances. We saw a prayer room was available for staff to utilise so they could continue to work whilst practicing their religion. Where staff were fasting for Ramadan, the registered manager had been responsive and sensitive to staff’s needs. The registered manager explained when staff had struggled with sleeping and eating, they changed their shifts to lates to support their routine and needs.

The provider has also been successfully involved in the sponsorship scheme. This scheme meant the provider employed 3 staff members from outside the UK and sponsored them regular hours at the home nurturing and mentoring them for 3 years. Those staff members were now at the point where they could complete their nursing qualification and should receive their pins in the next 6 months.

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.

Systems and processes were effective at monitoring and driving improvement within the service. Audits were in place, and these were effective at identifying areas for improvement and documenting actions taken. The provider had a multi-tier approach to monitoring, which meant all audits and analysis completed by the registered manager, were subject to a thorough review by 2 different members of the quality team. This ensured an unbiased approach was taken to auditing. However, there were some shortfalls found with the management of some medicine records which had not been identified prior to this assessment.

Statutory and regulatory notifications were submitted without delay and other professionals were notified where appropriate, through safeguarding notifications. Detailed records were kept of all meetings, discussions, performance monitoring, provider involvement, all with the clear outcome of driving performance and quality of care provided.

Staff told us they felt the service was organised, well run and had clear and effective communication from leadership and across the organisation. Staff understood the quality processes and what the requirements of their role was in contributing to these.

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. We saw evidence the provider involved people and their family in a meaningful way, and demonstrated they had good links with the local community resources. The service pro-actively engaged with staff and listened to their views, acting on their views to shape the service and culture.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. For example, the provider had been part of a year long research trial with the local falls team. This meant collaborative working with the care home support team and physiotherapists who supported people who were having falls. The registered manager reported a reduction in the falls as a result of emphasis in rehabilitation being put on developing people’s core strength to improve stability.

Kitchen staff were provided with specialised and innovative IDSSI training which developed their skills and abilities to make puree food look like the actual food it is. Visually improving the look of puree food had a positive impact on people’s appetites and intake.

Learning was evidenced where appropriate following people’s experiences of death. The provider worked in close partnership with nurses at the local hospice to develop new strategies for managing people’s deteriorating health and symptoms during the end-of-life stage.

There was evidence of provider wide action plans being completed monthly following analysis of accidents, incidents, falls and safeguarding events. This sharing of lessons learned throughout the provider group developed new innovative systems and promoted improvement in the service.