Birch Abbey

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. At our last assessment, we rated this key question good. At this assessment the rating

has changed to requires improvement. This meant some aspects of the service were not always

safe, and there was limited assurance about safety. There was an increased risk that people

could be harmed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The senior leadership team within the organisation was trying to instil a proactive and positive culture of safety based on openness and honesty. However, staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. One to one supervision for staff demonstrated reflective practice and shared learning, however this learning was not consistently embedded. For example, incidents of staff failing to turn on people’s sensors in their bedrooms continued to occur in January 2025 despite the issue being highlighted months earlier. The management team were taking appropriate action to address these concerns with individual staff members. Some relatives told us they did not always feel listened to when raising concerns with the registered manager and often had to raise the same issues multiple times. The registered manager told us they were offering monthly one to one meetings with families to improve communication and follow up on actions.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. For example, one person was admitted to the service with complex needs and behaviour, without staff having had appropriate training to manage the person’s needs. Some staff reported feeling unequipped to manage the risk related to some people who had been admitted to the service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. For example, some applications for Deprivation of Liberty Safeguards (DoLS) had not been followed up in a timely way. However, the provider did share concerns quickly and appropriately. Incidents involving restrictive practice were reported immediately to all relevant organisations, including CQC, and thorough internal investigations were carried out. Despite this, safeguarding logs were not kept up to date, meaning they did not consistently document actions taken or outcome of safeguarding concerns. Some relatives felt their family members were safe, but others did not. One relative commented, “I don’t feel [family member] is safe here.”

The provider demonstrated incidences where they had worked well with people to understand and manage risks. We found incidents where staff did not always provide care to meet people’s needs that was safe or supportive, however the registered manager identified this through internal analysis of incidents and shared learning with the wider team. For example, when the falls protocol was not correctly followed after one person had fallen. Some relatives raised concerns with us around the way wounds were managed and dressed. We found on several occasions dressings to wounds had not been applied correctly and required another member of staff to redress them. Some of these concerns had already been identified by the registered manager, and appropriate referrals to district nurses have now been made.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, several wardrobes in people’s bedrooms were found unsecured to walls. This posed a risk of injury to people if they were to fall or be pulled over. Following our visit, the maintenance person secured them. Additionally, we identified a blocked fire exit route, 3 fire doors that did not close properly, and an inappropriate smoking area outside the fire exit door. These concerns were all rectified immediately by the provider .

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, and development. They did not always work together well to provide safe care that met people’s individual needs. For example, moving and handling training was overdue for several members of staff. Prior to our visit, the registered manager had implemented a plan to prioritise and improve training for staff. Staff we spoke with told us they received regular supervision; however, they did not always feel this was supportive.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Daily cleaning schedules were completed, and records showed deep cleaning of people’s bedrooms was routinely carried out. We did find some out of date food in a satellite fridge and observed several staff members wearing false nails. We brought this to the registered manager’s attention and was assured this would be remedied.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. People were not always supported to receive their medicines safely. Several incidents were logged where medications, such as paracetamol, were administered without the required 4-hour gap between doses. However, the provider had recently increased their oversight of medications and identified these incidents through internal daily audits. The registered manager had taken appropriate action in relation to these incidents and implemented a plan to prevent recurrence.

Some people required thickened fluids for safe swallowing, however these were not always administered as prescribed; one pot of thickener prescribed for one individual was incorrectly being used for another person. This was rectified immediately by the registered manager. Furthermore, guidance for ‘when required’ medications was not up to date, which meant that staff did not have clear instructions to follow for administration of some medication. This was raised with the registered manager who shared updated guidance with us the following day.