Berrycroft Manor

Updated 16 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector, one pharmacist inspector and one Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Berrycroft Manor is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Berrycroft Manor is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced on day one.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and the local Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with ten people who used the service and two relatives about their experience of the care provided. We spoke with 12 members of staff including the registered manager, deputy managers, kitchen, maintenance, activity and laundry staff, care workers and senior staff.

We reviewed a range of records. This included seven people’s care records and nine medication records and related medicines documentation. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. Due to our concerns regarding medicines administration we requested further medicines documentation for us to review.

Updated 16 September 2022

About the service

Berrycroft Manor is a residential care home providing personal care and accommodation to up to 78 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 75 people using the service. The home is purpose built and accommodates people within six units across three floors.

People’s experience of using this service and what we found

People’s medicines were not always managed and administered safely. We were not assured people received their medicines safely and appropriately. People's care plans and associated risk assessments were not always current, accurate and did not always provide staff with the correct information they required to safely meet people's needs. Where people had specific, assessed care needs such as regular repositioning of people, staff did not always keep a clear record of the support they had provided. All environmental safety checks were in order.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Care files were person centred and reflected people’s preferences for their care and support.

We have made a recommendation around activity staff provision and meaningful activities for people who are cared for in their room.

Systems and processes to ensure oversight of the service were not always effective. Audits completed had not always identified the concerns we found on inspection. The management team were helpful and quick to investigate when we fed back our findings during the inspection. Feedback from people, relatives and staff was that the management team were supportive and approachable.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 12 January 2019). At this inspection we found the service requires improvement.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The inspection was prompted in part due to concerns received about medicine safety, people's needs not being met such as food, fluids and repositioning, staff behaviour and low staffing levels. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements in some of the areas reviewed. Please see the safe and well-led sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

During the inspection the management team were transparent, responsive and took steps to mitigate the risks.

Enforcement and Recommendations

We have identified breaches in relation to medicines administration, the management of people’s individual risks and management oversight.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.