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 1 quality statement within the well-led key question. We found 1 breach of the legal regulations in relation to good governance. During our assessment 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 been assessed, areas of risk for people had not been sufficiently assessed and staff were not trained in some specific areas required such as epilepsy. We found no evidence that people had been harmed. Shortfalls found during the assessment were not identified through the providers governance arrangements. However, we found staff were well supported, 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.

The new management team at the service were committed to improving the service and had formed good relationships with staff and people living at the service and their relatives. Staff felt supported by the management team of the service and were able to raise any concerns. We heard the interim manager was approachable. There were team meetings and regular supervisions, which were an opportunity for staff and management to discuss important information such as safeguarding, training needs and any changes to people supported at the service. Staff told us communication had improved. The interim manager told us they received support from the senior managers and the service was “thriving”. A senior manager told us compliance was monitored in many ways, including monthly and weekly meetings, regular audits and a service improvement plan. The plan had identified several areas for improvement which the service was currently working on.

The service was being supported by an interim manager and a senior management team. Quality assurance systems were in place, including a service improvement plan, provider audits and checks. The service improvement plan had identified some areas of improvement around people needing a review of their risk assessments, mental capacity assessments and best interest decisions. However, we did not see evidence of any mental capacity assessments in place for people. We found shortfalls had not been identified within people’s individual care plan reviews, such as where risk assessments were needed around finances and previous relationships between people living in the service. One person was able to sign their risk assessments but had not. Improvements were also needed in the providers business continuity plan following changes to the management in the service. We identified a breach of the regulation, good governance.

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.