Archived: Bereweeke Court Care Home

Updated 30 April 2021

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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Inspection team

The inspection team on the first day consisted of one inspector and one specialist nurse advisor. On the second day there were two inspectors. An expert by experience also made calls to relatives.

Service and service type

Bereweeke Court is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

Before the inspection, we reviewed all the information we held about the service including previous inspection reports and notifications received by the Care Quality Commission. A notification tells us about important issues and events which have happened at the service. We sought feedback from health and social care professionals. We used all of this information to plan our inspection.

The provider had not been asked to complete a provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make.

During the inspection

Some people were not able to fully share with us their experiences of using the service. Therefore, we spent time observing interactions between people and the staff supporting them in communal areas. We were able to speak with three people in a little more detail and with 11 relatives. We spoke with the registered manager, deputy manager / clinical lead, two registered nurses, and five care workers. We also spoke with two members of the housekeeping team, the maintenance person and chef. We reviewed the care records of four people in detail, but also looked at aspects of a further three people records. We looked at the records for four staff that had been recruited since our last inspection and other records relating to the management of the service such as medicines administration records, audits and staff rotas.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 30 April 2021

About the service

Bereweeke Court is a care home which provides nursing dementia care and residential dementia care. The service can accommodation up to 50 people. The home is located in a residential area close to community facilities. At the time of the inspection there were 21 people living at Bereweeke Court.

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

Improvements had been made which ensured that risks relating to people’s care and support had been adequately assessed or planned for. There were now sufficient numbers of experienced staff deployed at all times to ensure people’s safety. Medicines were managed safely. There were systems in place to learn from incidents and accidents. Infection control procedures were robust and the service was visibly clean, and no malodours were noted. Staff had a positive attitude to reporting concerns and not tolerating poor care.

Improvements had been made which ensured that staff undertook training relevant to their role and which kept their skills and knowledge up to date. Improvements were being made to ensure that care plans contained adequate information to guide staff. This remained a work in progress. We have made a recommendation that the audit systems in place be reviewed to support this. The mealtime experience had improved. We observed that it was a more person-centred and positive experience for people. People were supported to have maximum choice and control of their lives and staff and the systems in the service supported this approach. Legal frameworks regarding the use of consent were being followed. People had access to a range of health care professionals.

People told us that staff were kind and caring and treated them with respect. We observed that staff supported people to express their views and choices wherever possible. Staff engaged with people in a friendly and compassionate manner.

Improvements had been made to the culture within the service which meant that there was now a focus on the importance of delivering person centred care at all times. This was driven by the registered manager who had a clear value base which placed the person at the centre of their care. Improvements had been made which ensured that people were provided with access to activities which they enjoyed, and which were in keeping with their interests. This was a work in progress and further improvements were planned. People and their relatives continued to express confidence that they could raise any issues or concerns with any member of staff or the registered manager and that these would be addressed. People were supported to have a comfortable and pain free death when they were at the end of their lives.

Improvements had been made to the governance arrangements. Tools used to assess the quality and safety of the service were used effectively to help identify areas where quality of care was being compromised and to drive improvements. Feedback about the registered manager was very positive. Staff and relatives told us his appointment had had a positive impact throughout the service in terms of quality, culture and leadership. The registered manager was clearly driven to look at how the home might continue to improve in all areas.

Rating at last inspection

The last rating for this service was ‘Requires improvement’ (November 2019). We found four breaches of the Regulations. The provider completed an action plan to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned, comprehensive, inspection based on the previous rating and to check they had followed their action plan and to confirm they now met legal requirements

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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