Birkin Lodge

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 newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 did not always have a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were not always learnt to continually identify and embed good practice. There were records of organisation wide learning from events that had taken place at the service and across other the providers other services. However, it was not always clear that lessons learned had been embedded. For example, there had been an incident on 18 December 2024 where a person fell. It was identified that their sensor mat had been unplugged by staff. The incident had been reviewed by the management team and actions taken which included talking with staff, increased checks of the service and staff training. There was another incident on 27 December 2024 where a person fell, again it had been identified that the sensor mat had been unplugged by staff which meant that staff had been unaware that the person had mobilised. Despite the negative evidence above, staff told us lessons learned were communicated widely. A staff member said, “Lessons learned are shared in clinical meetings with nurses, seniors and managers and with care staff as well as at the monthly meeting and ‘all staff’ meeting.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. When people were supported to go to hospital, either through routine or planned admission, emergency admission or consultation day visit, support was in place as well as hospital passports. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital. People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. The registered manager explained that they worked with others to resolve problems and make improvements. The service had maintained regular contact with local authority social workers. This included good ongoing work with the GP and other health and social care professionals. Staff told us they were able to contact the GP and other health professionals such as tissue viability nurses and hospice. A staff member said, “The GP practice are good. If there are urgent concerns that cannot wait until the ward round, then we call the Home Treatment Team. We have good links with them as well as the Tissue Viability Nurses.” A health care professional told us, “On my last visit I found the staff engaging. There was a staff nurse with me during the assessment. She had to leave halfway through assessment but was replaced with a carer who again was engaging with the resident.”

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 were safe and were protected from harm. A person told us about something they did not feel safe about which had happened within the last 24 hours. They had not told anyone. We reported this to the registered manager who took appropriate action. Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Safeguarding policies included information about safeguarding children from abuse. Safeguarding training included safeguarding children. This is because staff in care services come into contact with children as part of their work. The management team had reviewed processes and learnt lessons from safeguarding incidents. We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Most people required physical support to move around the service. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed. A staff member said, “If a staff member reported safeguarding concerns, I would note them down, talk with the staff member and person to investigate it and report it to my superior. [Registered manager] would definitely deal with it, and it would be taken very seriously. I would also raise a safeguarding alert with the local authority.”

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. Risk assessments were clear, comprehensive and up to date. They provided enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. Staff had access to the risk assessments and care plans. Risks in relation to pressure area care were adequately monitored and mattresses were at the correct settings to maintain people’s skin integrity. People had been frequently repositioned in accordance with their care plan. Epilepsy risks were documented, understood or identified. Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. People were supported to move around the service safely and were supported to spend time where they chose. People were given food and fluid in a consistency which was in accordance with their assessed needs (including diabetic diets). The food was well presented, and people seemed to be enjoying the experience. Staff told us about safe ways of working with people which demonstrated they knew them well. People and relatives told us about falls and incidents that had occurred which had been acted upon. For example, people had crash mats in place to protect them if they fell from their bed and equipment was used for their safety. A person said, “I can’t walk now, I need machines to lift me around.”

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. There was no dementia friendly signage around the service to provide way marking to communal areas of interest such as dining room and lounge. Toilets and bathrooms and people's rooms did not have dementia friendly signage to help people understand what was behind the door. Some people had their names on their bedroom doors, most people did not. We observed some people who were mobilising independently who needed help to direct them. We raised this with the registered manager, and they added this to their action plan of improvements required. We observed that risks to people related to the building were not always well managed. A fire escape route from the lounge area to the front of the building was damaged and hazardous. We reported this to the registered manager. Contractors undertook emergency works to the escape route 2 days after our site visit. Maintenance tasks appeared to have been completed in a timely manner. Rooms were mostly clean and tidy and had been personalised in accordance with the person’s wishes. A person’s room had a strong odour. The registered manager explained the flooring was waiting to be replaced, this could not be done until a suitable room was found for the person to move to. The provider had systems and processes in place to detect and control potential risks in the care environment. This made sure that the equipment, facilities and technology supported the delivery of safe care. Essential servicing and maintenance of the service, utilities and equipment had taken place. The maintenance team told us they carried out daily checks of the service including people’s rooms, they then completed any maintenance jobs that were needed. A relative told us, “The home is very clean, it’s not purpose built but it’s nice.”

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, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. People and relatives gave us mixed views about staffing levels; “The bell is responded to quickly, but this morning my bell rang for a long time”; “The staff are very attentive” and “I tend to go once a week, I have often been there when mum has rung the bell to use the commode, I have to go and hunt for people.” Our observations confirmed people sometimes had to wait for staff to respond to their call bells. Staff provided mixed feedback; “I think there is enough staff on shift”; “Sometimes in the morning we are not able to answer the call bells quickly as we are already helping someone else” and “Sometimes it’s a bit short, it does impact the care because you can’t do what you need to do. I can only spend a couple of minutes with the residents; they get their pad changed, washed. No time for anything else.” Staff had been safely recruited. All required checks had been carried out. The information helps employers make safer recruitment decisions. Nurses were registered with the Nursing and Midwifery Council. The provider had made checks on their personal identification number, registration status and renewal date. Staff had regular supervision meetings, induction was a mixture of training and shadowing experienced staff to gain confidence and experience. The training matrix showed that most staff had completed mandatory training. Staff had not completed epilepsy awareness training, despite supporting people with epilepsy. There had been no impact of this because nurses were on shift. The registered manager added this to the action plan for improvement. Nursing staff had completed additional training to ensure they had the skills and knowledge to meet people's nursing needs.

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. The provider had systems and processes in place to assess and manage the risk of infection. The provider had a daily cleaning programme in place. The service employed housekeeping staff to carry out daily cleaning, cleaning schedules were in place which included deep cleans for people’s rooms. Infection control audits were completed regularly and actions taken if any issues were found. The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. The kitchen areas were clean and well managed. We observed that the staff were using PPE effectively and safely. We were assured that the provider was promoting safety through the layout and hygiene practices of the premises. There were no restrictions to visitors. We observed visitors coming and going freely during the assessment. Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member told us, “We have plenty of PPE.” A relative told us, “Cleanliness is good, there are times when it smells due to commodes being emptied but normally it smells fine.” A person said, “My room is tidy and clean.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The provider had systems and processes in place to manage medicines. Some improvements were identified. The return and disposal of medicines no longer required had not been carried out in line with NICE (National Institute for Health and Care Excellence) guidelines ‘Managing medicines in care homes’ or the provider’s medicines policy. We discussed this with the registered manager who took action to change practice and put safer recording processes in place. Medicines care plans and risk assessments were detailed and person-centred. They provided good information to support staff to understand people's care needs and linked to care planning for specific conditions. The ordering process for prescribed medicine was effective, and we were able to reconcile medicines stock with prescribing. The management team carried out regular medicine audits. People received their medicines from trained staff. The staff informed us they received training and were competency assessed to handle medicines safely. Nursing staff administered Insulin injections to those who required this. People were supported by the local GP and had regular medicines reviews. People received their medicines safely. A relative told us, “The staff are very efficient with medicine, at lunch time a lady in a red overall goes around giving out the medicines.” We observed the staff were polite, gained consent, and recorded the administration of medicines on the medicines administration record (MAR).