Birkdale Village Care Home

This procedure tells every member of staff exactly what to do if they see, hear or suspect that an adult in our care may be being abused, neglected or is at risk of harm. It exists so that anyone — regardless of role or experience — can respond correctly and protect the resident. Safeguarding is everyone's responsibility.

As a CQC-registered provider we are legally required to tell CQC about certain events that happen in the home. This procedure lists what must be notified, who does it, and by when, so we never miss a statutory notification — which is itself a breach of regulation.

To make sure every accident, incident and near miss involving a resident, staff member or visitor is recorded, acted on, and — where the law requires — reported to the HSE under RIDDOR. Good incident reporting protects people, identifies risks, and is essential evidence of safe care.

To give every worker a clear, safe route to raise serious concerns about wrongdoing, poor practice or risk to residents — including concerns about managers or the provider — without fear of reprisal. Whistleblowers are protected by law.

To ensure that when a resident dies, they are treated with dignity and respect, the correct people are informed promptly, the legal and regulatory steps are followed, and the family and other residents and staff are supported. This applies to both expected and unexpected deaths.

To ensure medicines are ordered correctly, received and checked accurately, and stored safely and securely at the right temperature, so residents always have the medicines they need and nothing is lost, expired or misused.

To ensure medicines are given safely, to the right resident, in the right way, and accurately recorded on the Medication Administration Record (MAR). Only staff who are trained and have had their competency assessed may administer medicines.

Controlled drugs (CDs) are medicines with additional legal storage, recording and witnessing requirements because of their potential for misuse. This procedure ensures CDs are stored, administered, recorded and disposed of lawfully and safely.

To make sure medication errors and near misses are reported openly and acted on quickly to keep residents safe, and to learn from them. The culture is one of openness, not blame — hiding an error is far more dangerous than making one.

A regular medication audit checks that medicines are being managed safely and that records are accurate and complete. It catches problems early and provides evidence of good governance to CQC.

To ensure unwanted, expired, discontinued or part-used medicines — including controlled drugs — are disposed of safely, legally and with a clear audit trail, protecting residents, staff and the environment.

To ensure the home always has enough suitably skilled staff on duty to meet residents' assessed needs safely, at all times of day and night. Safe staffing is a legal requirement and the foundation of safe care.

To make sure that when a staff member calls in sick or fails to arrive, the gap is filled quickly and safely so the home never drops below safe staffing levels.

To ensure all new staff are recruited safely and lawfully, with the right checks completed before they start work, so that only suitable people care for our residents. Safe recruitment is a legal requirement (fit and proper persons).

To ensure everyone working with our residents has an appropriate, current Disclosure and Barring Service (DBS) check, so that barred or unsuitable individuals do not work in the home.

To ensure every staff member completes the mandatory training they need for their role, kept up to date, so care is safe and competent. A training matrix gives an at-a-glance picture of who is trained and what is due.

To ensure every new staff member (including bank, agency and volunteers) is properly introduced to the home, understands their role and key safety procedures, and is supported to become competent — so they can work safely from day one.

To ensure every resident has an accurate, person-centred care plan that sets out their needs, wishes and how their care is delivered, and that it is kept up to date. The care plan is the single source of truth for how to care for each resident safely and with dignity.

To identify risks to each resident's health, safety and wellbeing and put in place measures to reduce them, while still respecting the resident's choices. Risk assessment is how we keep residents safe without taking away their independence.

To ensure that where a resident who lacks capacity is deprived of their liberty for their own safety, this is lawfully authorised, regularly reviewed, and least-restrictive. DoLS protects residents' human rights.

To ensure residents are supported to make their own decisions wherever possible, and that where a resident cannot make a particular decision, any decision made for them is lawful, in their best interests and least-restrictive — in line with the Mental Capacity Act.

To ensure new residents are admitted safely and smoothly, that the home can genuinely meet their needs, and that everything is in place for good care from day one.

To protect residents, staff and visitors from fire, ensure everyone knows what to do if a fire occurs, and that every resident has a personal evacuation plan (PEEP) suited to their needs.

To prevent and control the spread of infection in the home, protecting residents (who are often vulnerable), staff and visitors. Good IPC is a continuous, everyday responsibility.

To control the risk of Legionella bacteria in the water system, and to prevent scalding, protecting residents and staff. This is a legal duty under health & safety law.

To ensure all equipment used in the home — especially moving & handling equipment like hoists and slings — is safe, serviced, inspected and used correctly, protecting residents and staff from harm.

To ensure food is prepared, cooked, stored and served safely, meeting food hygiene law and protecting residents from foodborne illness, while meeting their nutritional and dietary needs.

To ensure staff respond quickly and correctly to a medical emergency or first aid situation, getting the resident the right help fast and following their care wishes (e.g. DNACPR).

To ensure the home maintains its CQC registration correctly, keeps registration details up to date, meets the fundamental standards, and is always ready for inspection. Operating outside the terms of registration is unlawful.

To ensure complaints and concerns are welcomed, handled fairly and promptly, and used to improve the service. Residents and families must find it easy to raise concerns and trust they will be listened to.

To ensure the home holds all the insurance cover it legally and prudently needs, that it stays in force, and that claims and incidents are handled correctly — protecting residents, staff and the business.

To routinely check the quality and safety of the service, find problems before they cause harm, and continuously improve. A strong audit cycle is the heart of being 'Well-led' and keeps the home inspection-ready.

To ensure personal and sensitive information about residents and staff is kept confidential, secure, accurate and used lawfully, in line with UK GDPR and the Data Protection Act. Care records contain highly sensitive data and must be protected.

What the BVCH Portal is, who uses it, how to log in, and what it contains. The system used to run the whole home — read this first.

Where the manager spends most time: the dashboard, weekly sign-off, the weekly/monthly/quarterly audits, staff files, residents, compliance and incidents — all mapped to CQC.

David's weekly room and fire-safety checks and monthly water/extinguisher checks on the portal, and how to record them.

Tina's daily and weekly cleaning, deep cleans and logs on the portal — the home's infection-control evidence.

The kitchen team's daily temperature and hygiene checks, opening/closing and stock on the portal — food-safety evidence.

The complete manager portal handbook with every screen and step in detail (Andrea's full reference and sign-off agreement).

The full resident handbook: welcome, admissions, fees, rooms, meals, care plans, activities, visiting, rights, CCTV, complaints, fire procedure, leaving the home and CQC.

The marketing brochure: who we are, our values, facilities, services and activities. Good for enquiries and showing prospective families.

The live online application form. Share this link with anyone wanting to apply for a role. Opens in the browser.

What we do with an applicant's data when they apply: what we collect, AI-assisted scoring, legal basis, retention and their rights.

A structured, conversational exit interview to use when a staff member leaves — captures honest feedback to improve the home.

Signed by every new starter to confirm they have received and read the staff handbook.

The full list of policies a staff member confirms they have read and understood — safeguarding, medication, infection control, fire and many more.

The staff agreement on personal mobile phone use during shifts — kept on the staff file.

The voluntary 48-hour week opt-out under the Working Time Regulations 1998.

Signed at induction and yearly — confirms the staff member understands the CCTV policy and the rules around footage.

Front sheet listing every document in the Portal Data Protection pack.

How we protect personal data held in the in-house Portal: what we hold, lawful basis, security, retention, breaches and staff duties.

Data Protection Impact Assessment for the Portal — the risks of processing resident and staff data and how they are reduced.

Record of Processing Activities — what data the Portal processes, why, the legal basis and who it is shared with.

Plain-English summary of how the Portal is kept secure: encryption, access control, backups and logging.

What residents are told about how their data is used in the Portal and their rights.

What staff are told about how their data is used in the Portal and their rights.

How to handle a Subject Access Request (SAR): verifying identity, the one-month timescale, and what to provide.

What family members are told about how their data is used in the Family Portal and their rights.

The master correction sheet: every conflict in the compliance pack and the exact wording fix required to make it consistent.

Master register of the technology/portal compliance documents and their status.

Front sheet of the CCTV compliance folder, plus the pre-inspection checklist.

The primary CCTV policy: purpose, where cameras are, retention, access, signage and sign-off.

Data Protection Impact Assessment for the CCTV system — risks and safeguards.

Legitimate Interests Assessment — the lawful basis for operating CCTV.

The public-facing CCTV privacy notice for residents, families and visitors.

One-to-one CCTV consultation form for each resident who has capacity.

Best-interests decision form for residents who lack capacity to consent to CCTV.

Log of responses and objections raised during CCTV consultation.

Record of every time footage is viewed — who, when and why.

Record of every time footage is shared outside the home (police, CQC, ICO).

How to handle a request to see CCTV footage of oneself, with a log.

Every camera listed with location, install date and last check date.

Weekly record confirming each camera is working.

Record of footage saved off the system for an incident.

Record confirming CCTV signage is in place at every entrance and covered area.

Record of the recorder's security: password changes and physical security.

The list of people allowed to view footage — kept current as staff change.

Reception leaflet telling visitors they are being recorded and why.

The yearly CCTV review and the log of any data breaches.

Practical building knowledge anyone running the home needs — where the water stopcock and other shut-offs are, in an emergency or day to day. A growing reference.

What to do when something disrupts the home — power, water, IT, staffing, building or supplier failure — to keep residents safe. Includes the key contacts and partner-home arrangements.

The Local Authority quality-monitoring questionnaire and the home's completed answers — useful evidence for CQC and Sefton reviews.

The platform we use for ALL staff training and where the live training matrix lives. Includes the Flexebee support contact (Ciaran McMullen).

Our digital care system (mCare). Care plans, risk assessments and daily resident records recorded on handheld devices. eMAR coming soon.

Where all the home's CQC-required policies are kept and automatically updated. The formal policies behind the procedures in this hub.