Birkin Lodge

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 newly registered 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.

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.

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 were passionate about the service and wanted to ensure people had good quality care and improved outcomes. The staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “There is a good culture, communication is improving, everyone helps each other more” and “We try and make a nice atmosphere. It is a nice place to work, we need to keep staff and provide training as some staff don’t have much experience, but they are eager to learn, I appreciate them.”

The provider had 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The management team knew people well and were passionate about making sure people received good quality care. The registered manager told us, “We are a small home we know each other well and the residents.” The registered manager shared that they had reported maintenance and building concerns to the provider, these had been added to the provider’s action plan. There was a clear management structure in place with the registered manager, who became registered with CQC whilst we were undertaking the assessment and a deputy manager. Nurses provided clinical support to people, and they were supported by senior care workers and care workers to provide care and support. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by an area manager who visited the service regularly to undertake checks and audits. The management team told us they were well supported by the provider.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Complaints processes were available. A person told us, “[The registered manager] is very good. I would talk to [registered manager], and I know that he will put it right.” Relatives confirmed the registered manager was responsive and accessible and had followed up any concerns or issues they had, and they were satisfied with the response. Staff confirmed they were invited to meetings and encouraged to contribute. They mostly felt listened to. Staff meeting minutes evidenced that these took place regularly. Staff told us they were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff felt they were treated well and supported equally by management. The provider had processes in place to encourage an inclusive culture. The workforce was diverse, and support was in place for staff. Any issues could be discussed openly at staff meetings or during supervision. The registered manager had an open-door policy and staff told us they would not hesitate to speak to the registered manager if they needed to. Staff reported the staff all worked together well as a team. Nursing staff equally shared how they supported the care staff. A member of nursing staff said, “I always tell staff after handover if they need me for anything come and find me and I will help. I help out the staff.” They explained when they are at work, they are there to work as a team to help people. Another staff member said, “Nurses are very good, and they help a lot. We are a good team. I enjoy it.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had systems in place to check the quality of the service. Audits had been carried out. There were monthly audits of infection control, care plans, medicines, call bells, falls and wounds, incidents and accidents, health and safety, fire, dignity and mealtime experience. The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example, the environment fire safety audit had not picked up the damage to the external fire escape, and audits had not detected that people were not having baths and showers as frequently as they had been assessed and that fluid records were not always up to date and accurate. Actions from audits had been recorded and the management team had signed off items that had been addressed. Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that all incidents had been appropriately reported. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so. Staff said the management team were supportive and approachable. Staff we spoke with were confident that they could discuss any concerns with the management team, and these would be acted on, they were aware of how to escalate concerns to senior management or outside of the organisation. Staff told us they liked working in the service.

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. The management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities, end of life care, the local authority and through good links with GP’s. A healthcare professional told us, “I have had visits with a couple of the registered nurses there and they always appear interested and take on board advice given.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The registered manager told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered manager updated CQC on the progress of these actions. Staff meetings were scheduled and held to discuss feedback and embed learning and improvement to benefit the people living at the service.