Birch Abbey

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 requires

improvement. At this assessment the rating has remained requires improvement. This meant the

management and leadership was inconsistent. Leaders and the culture they created did not

always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance at the service.

This service scored 57 (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. The management team recognised challenges the service faced over the previous 12 months and was committed to improving the staff culture. To do so, they had set up culture workshops, increased training opportunities and focused on promoting the inclusivity of agency workers.

Leaders did understand the context in which the provider delivered care, treatment and support. Senior leaders did have the skills, knowledge and credibility to lead effectively. However, ahigh turnover of managers had created a lack of consistency within the service. Whilst some relatives acknowledged an improvement in the care provided since the current manager joined the service, most staff members felt the registered manager was not visible. Some staff and relatives did not feel included and did not feel they knew senior managers well or could approach them. Further time was required to evidence whether the increased oversight of the service from senior managers had a positive impact on culture to support the delivery of high-quality care.

People did not always feel they could speak up and that their voice would be heard. One staff member told us, ‘I have tried to raise issues with [registered manager], but they get ignored.” Some staff did not feel comfortable to raise concerns to senior managers through fear of repercussions. The provider acknowledged these concerns and had already facilitated staff forums and culture workshops to encourage staff members to speak up.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. While some staff felt they were treated fairly, others did not. The provider had policies and processes in place to protect and promote the rights of the whole staff team, and the registered manager provided us with examples where staff had been supported and reasonable adjustments made. However, some staff members did not feel they were supported with appropriate reasonable adjustments or considerations.

The provider understood it’s responsibilities and had clear roles, systems of accountability and governance. However, they did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were not always effective in monitoring the safety of the service or identifying areas for improvement. For example, issues identified in a fire risk assessment in January 2024 regarding the smoking area and gaps in some fire doors had not been rectified at the time of our assessment. Daily audits did not identify some of the concerns we found during the assessment, for example, wardrobes being unsecured to walls.

Additional concerns related to staff not consistently following care plans and the absence of mental capacity assessments where needed. For one person subject to DoLS, there was a delay in submitting the necessary renewal application form, and for others, there were delays in following up on updates for pending applications.

The provider had not always delivered training to staff that was specific to meeting the needs of people living in the home, and some mandatory training was overdue. The provider had an action plan in place and had already improved the percentage of completed training and offered additional training to fill some of the gaps.

Furthermore, equipment for people was not always managed appropriately. For example, slings specific to individuals had not been labelled correctly. This was resolved following our inspection. An action plan has been put in place to address the improvements needed.

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. However, people told us they did not always have access to the community. One person reported they had not been to church for a couple of years. The registered manager acknowledged this and had contacted the local church to arrange future visits to the home.

Following a series of incident, the provider had recently prioritised continuous learning, innovation and improvement across the organisation. They had improved their training and learning in order to contribute to safe, effective practice and research. For example, in November 2024, all staff completed positive and restrictive physical intervention training, accompanied by one-to-one supervisions on the subject. A positive behaviour support and dementia lead was also appointed to help embed this learning.