Birch 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

We assessed all the quality statements in the key question of well led. The provider had identified areas for improvement but had yet to work through the specifics of how and when each area would be addressed. Staff said although there had been some changes in the staff team they were committed to the aims and values of the service. Staff told us there was a positive culture within the service and they felt supported. Staff thought they worked well as a team.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff understood the aims and values of the service were to ensure people lead active and fulfilling lives. Staff said there was a positive culture, good communication and were proud to work for the service. One staff member told us, “Here, no question is a silly question”.

Processes were being developed to include the staff team in discussions about what the service was doing well and the priority areas where it could improve. These areas identified would then be included in the services audits to have make any necessary changes.

Staff told us they felt supported by the registered manager. One staff member told us, " It is a great team. We do get told when we do a good job”. The registered manger knew people well as they had worked at the service for many years and also stepped in to support people with their care when this was required. They demonstrated a genuine passion for people and for making any necessary improvements to ensure people were provided with the best care. The staff team had nominated the registered manager for an award due to their effective leadership.

The registered manager kept their learning and development up to date. They completed training, reviewed CQC updates had regular discussions with other care home managers. They also attended skills for care registered manager conferences. Skills for Care supports adult social care employers to deliver what the people they support need, and what commissioners and regulators expect.

Staff said there was an open-door policy whereby they felt confident to speak up about any issue. This was because the registered manager was available and listened and responded to any concerns.

The provider had systems and processes in place to foster a positive culture where people felt they could speak up and have their voices heard. There was a Freedom to Speak Up policy in place and information on how to make a complaint.

Staff spoke positively about their experiences at work. They told us they were treated fairly by the registered manager. As a result of the registered manager’s approach, staff felt they worked well as a team and were treated equally.

The provider had systems in place to ensure that there was an inclusive culture. Staff told us that the culture of the service was open, transparent and supportive, and they all worked together well as a team. The workforce was diverse, and support was in place for staff.

The registered manager told us quality monitoring processes were being strengthened to ensure they were effective. Staff told us there were regular visits to the service by a representative of the provider to check the quality of care being provided.

The provider had an audit programme in place and regular audits were undertaken by staff, the registered manager and a visiting member of the management team. An action plan had been developed in October as a number of areas for improvement had been identified. Some actions had been completed such as completing medication protocols and night staff being training in administering paracetamol. Other areas which had yet to be completed were mental capacity assessments and reviewing positive behavioural support plans. There were no timescales for the completion of these shortfalls, nor had it been identified which specific areas of people’s mental capacity or support plans needed review. The registered manager told us that they were receiving support from a manager at another of the providers services to complete these actions.

People and their relatives told us they had seen healthcare professionals and other agencies when they needed them. People told us they went to the local shop and staff confirmed people were well known in the local area due to their community presence.

Staff told us that people were referred to the appropriate agencies to enhance their care and make sure they were getting the care and treatment they needed. The provider knew to contact independent advocates when people did not have family or friends who could help them to make choices and decisions.

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and the local authority contracting teams. This enabled them to share information and learning with partners and collaborate for improvement.

Staff told us they were able to share any ideas for improvement with the registered manager but felt the service did not have an area in which changes were necessary. Staff were excited about the construction of a sensory room in the garden. They felt this would greatly benefit the people who used the service as they would enjoy the lights and sensory equipment which would be provided.

The provider had identified that processes for learning and improvement were not as effective as they should and was making some changes. The provider had identified that oversight of the service needed to be strengthened and a representative of the service visited weekly. At their last visit they focused on staff training, medication administration and staff knowledge of mental capacity and safeguarding. Management reports evidenced that improvements were being made in these areas but further work was needed. Staff meetings, supervision and surveys were used as an opportunity to share ideas and feedback concerns. For example, at a staff meeting learning was shared from a fire drill about which door staff should use the exit the building in the event of a fire.