Birnbeck House - Care Home Learning Disabilities

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• 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 one quality statement within the Well-led key question and found areas of concern. We found one breach of the legal regulation, good governance. The score for this area has been combined with scores based on the rating from the last inspection, which was good. The Well-led key question has now been rated as requires improvement. During the assessment we found there was a lack of effective governance, management and accountability arrangements in place. Systems were either not in place or robust enough to provide adequate oversight of the service. This placed people at risk of harm. We identified some concerns with the oversight of key areas of people's care. For example, people’s mental capacity to make decisions had not always been assessed, areas of risk for people had not been sufficiently assessed and staff were not trained to the required level in some specific areas required such as learning disabilities and autism. However staff were well supported, team meetings and supervisions were held and quality assurance systems were in place.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us team meetings and other meetings held in the home were useful and they could make suggestions, and they all received supervision, which they also found useful. Staff felt supported by the management of the service. They told us, “Management has been good even through a lot of changes”. They confirmed the interim manager was, “nice”. Senior managers confirmed they visited the service regularly to undertake visits and audits, they felt improvements were being made following some changes in the management of the service. The interim manager confirmed they were keen to make improvements to the service and they were working with the staff team and the local authority safeguarding team around this. However the interim manager and senior management team for the service had not identified many of the issues we found during our inspection.

The service was being supported by an interim manager and senior management team. Resident meetings were held and were an opportunity to discuss meal choices, if people were happy with their care and if they had any suggestions for the service or manager. The service was displaying their rating as required. The business continuity plan needed reviewing and updating following changes to the management within the service. Quality assurance systems were in place including a service improvement plan. There were various areas the provider’s audits had identified where improvements were needed, in areas such as training and people’s care plans. However, individual care plan audits and other checks were not always identifying specific concerns, such as where people needed individual mental capacity assessments and best interest decisions and risk assessments. We also found where incidents had occurred they were not always being reported or recorded as an incident unless it had been observed, and that referrals were not always being made when people’s needs had changed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.