Berry Hill Care Home

We found the following examples of good practice.

• We observed good social distancing in communal areas with seating being arranged to provide adequate space between residents.

• Residents were closely monitored for any symptoms of COVID-19 and prompt action was taken to test and isolate suspected cases.

• There was a provider application on the computer which enabled the care home manager to see staff training compliance and testing and vaccination status of all staff and residents at a glance.

• Vulnerable or at-risk staff received risk assessments and if appropriate were offered amended duties to reduce their clinical contact with residents.

Berry Hill Care Home is registered to accommodate up to 66 older people in one building. Some of these people were living with dementia. At the time of the inspection, 38 people were using the service.

At the last inspection on 7 September 2017, we asked the provider to take action to make improvements to the safety of the service, the assessment and management of the risks associated with people’s care, the support people at risk of dehydration received, care planning documentation and overall governance of the service. During this inspection we found the required improvements had been made however, further work still needed to be done to ensure all care planning documentation was reflective of people’s current needs.

During the home’s previous inspection on 7 September 2017, we rated the home overall as ‘Requires Improvement’ with the question, ‘Is the service well-led?’ rated as ‘Inadequate’. Because of the improvements made at this home since their last inspection, the overall rating has now changed to ‘Good’ although the question, ‘Is the service responsive?’ remains rated as ‘Requires Improvement’. The details of the reasons why are explained in the summary below and in the body of the main report.

A registered manager was present during the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People felt safe living at the home. The risks to people’s safety were now appropriately assessed and acted on. The process of investigating accidents and incidents and reducing to the risk to people’s safety had improved. Medicines were now stored and handled safely. There were enough staff in place to support people. Staff understood the processes for protecting people from avoidable harm. Robust recruitment procedures were followed to ensure people were protected from unsuitable staff. The home was clean and tidy and staff understood how to reduce the risk of the spread of infection.

People were now supported to remain hydrated and records used to record the amount people drank was recorded and monitored. People’s health needs were assessed and provided in line with current legislation and best practice guidelines. People told us staff knew how to support them. Staff were well trained, although some staff required refresher training to ensure their practice met current best practice guidelines. Staff felt supported by the registered manager. The registered manager had built effective relationships with external health and social care organisations and people’s health was regularly monitored. The environment had been adapted to ensure people were able to lead fulfilling lives. However, more directional signage was needed to support people with independent movement around the home. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice, although some best interest decision documentation required more detail.

People felt staff were kind, caring and compassionate. Staff treated people with respect and dignity. People’s privacy was respected and staff spoke discreetly when discussing people’s personal care needs. People felt listened to and staff understood how to communicate effectively with people. People were encouraged to do things for themselves and access to an advocate was provided if they needed one.

Some improvements had been made to the care planning process since our last inspection. Many of the records we looked at were fully reflective of people’s current health needs. However, more work was still needed to ensure all care records were up to date. End of life care plans were in place, but some of these lacked detail. Prior to moving to the home assessments were conducted to ensure people’s needs could be met at the home. People felt there were sufficient activities at the home and they were able to follow their own interests. People’s care records were person centred and guidance was provided for staff on how each person would like to be cared for. People felt their personal preferences and choices were respected. People were cared for without discrimination and systems were in place to support people who had communication needs. People felt able to raise a concern with the registered manager but were unsure of the formal process for doing so.

A new registered manager was in place. They, with support of the senior management team had made improvements to the home since our last inspection. There were now clear quality assurance processes with staff given responsibility to assist the registered manager with identifying concerns and acting on them. A detailed action plan was in place to further assist the registered manager with making longer term, sustainable improvements to the home. People felt able to give their views about the service. Staff felt valued and felt the registered manager had made a positive impact since joining the home. Staff were now held accountable for their actions.

At our previous inspection, on 22 and 23 May 2017, the service was rated as requires improvement and multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. Following our last inspection we took action against the provider and issued a Warning Notice to ensure that improvements were made in relation to the governance of the home. The provider was required to be compliant with this notice by 1 August 2017. In this inspection we found that the provider had not made the required improvements in this area and remained in breach of this legal regulation. During this inspection we also found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to safe care and treatment and person centred care. You can see what action we told the provider to take at the back of the full version of the report.

The service had a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was relatively new to the service and had been in post for a period of four months at the time of our inspection visit.

During this inspection we found that the systems in place to reduce risks associated with people’s care and support were still not always effective and this exposed people to the risk of harm. Although we found that people received their medicines as prescribed, medicines were not stored safely at all times. Safe recruitment practices were followed to ensure that staff were suitable to work with people who used the service.

People’s day to day health needs were met, however, there was a risk that people may not receive appropriate support with specific health conditions due to a lack of information in their care plans. Systems in place to ensure people had enough to drink were not always effective and this placed people at risk of dehydration. People were supported to have enough to eat and were given choices and assistance as needed.

People were enabled to make decisions. Where a person lacked capacity to make a certain decision they were protected under the Mental Capacity Act 2005. There were enough staff available to keep people safe and meet their needs. People were supported by staff who received training, supervision and support.

People were not treated with dignity and respect at all times and their right to privacy was not always respected. People could not always be assured that they would receive support that was based upon their individual needs and preferences as care plans did not consistently reflect people’s current needs. Improvements were underway to ensure that people were provided with compassionate, dignified care at the end of their lives.

The majority of staff were kind and caring in their approach. People felt involved in day to day decisions about their care and were offered the opportunity to get involved in planning their support. Staff understood how people who used the service communicated and supported them to maintain their independence. People had access to advocacy services if they required this to express their views. There were systems in place to respond to and investigate complaints. People were provided with opportunity for social activity.

Although during this inspection we found that people supported to maintain relationships with family and friends we were also aware of a complaint regarding visiting rights which had been upheld by the Local Government Ombudsman. The provider was in the process of making changes and improvements based upon this at the time of our inspection.

The service was not well led. The service has a history of non-compliance with the fundamental standards – the standards below which services should never fall. Although improvements were found in some areas at this inspection, we also identified a number of areas where the provider had failed to make the required improvements. There were not sufficient management systems in place to ensure the safe and effective running of the service and this had a negative impact on the quality of service people received. Systems in place to monitor and improve the quality and safety of the service were not effective and timely action was not taken in response to known issues. Feedback from people who used the service and their families was not always used to drive improvement.

The provider was responsive to our feedback and following our inspection informed us of a number of changes, in progress and planned, intended to ensure the safe and effective running of the home.

At our previous inspection, on 11 October 2016, the service was rated as requires improvement and multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. During this inspection we found that although some improvements had been made there remained concerns in relation to the quality and safety of the service. This resulted in us finding new and ongoing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to safe care and treatment, staffing and good governance. You can see what action we told the provider to take at the back of the full version of the report.

The service had a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we found that the systems in place to reduce risks associated with people’s care and support were not always effective and this exposed people to the risk of harm. Risks in relation to people's care were not planned for appropriately to ensure people received safe care and people's care records did not always contain sufficient guidance for staff to minimise risks to people. Medicines were not always stored or managed safely.

Staff were not deployed effectively to meet people’s needs and keep them safe. People could not be assured that action would be taken to protect them from harm or abuse as staff were not sufficiently skilled in identifying and acting upon concerns.

Safe recruitment practices were followed and people were supported by staff who received training, supervision and support. We found staff had limited knowledge in some areas and the registered manager took swift action to address this.

People were enabled to make decisions. Where a person lacked capacity to make a certain decision they were protected under the Mental Capacity Act 2005. We found there was a risk that some people may not be supported in the least restrictive way possible.

People’s day to day health needs were met, however, there was a risk that people may not receive appropriate support with specific health conditions. People were supported to have enough to eat and drink.

People could not be assured that they would be treated with dignity and respect at all times. People were not always offered the opportunity to be involved in the planning or reviewing of their care plans. However people felt involved in day to day decisions about their care and support.

People could not always be assured that they would receive support that was based upon their individual needs and preferences. People were not consistently provided with the opportunity to discuss and plan for the end of their life. In addition to this care plans did not all contain accurate, up to date information about the support people needed.

Staff were kind and caring and respected people’s right to privacy. People were provided with some opportunity for social activity and were supported to maintain relationships with family and friends.

People were supported give feedback about the service, raise issues and concerns and there were systems in place to respond to complaints. Staff were also involved in giving their views on how the service was run.

Systems in place to monitor and improve the quality and safety of the service were not effective and timely action was not taken in response to known issues.

Records relating to the care and treatment of people who used the service were not consistently accurate or up to date. Sensitive personal information was not always stored securely.

The management team were responsive to feedback and swift action was taken to address some areas of concern raised during this inspection.

Accommodation for up to 66 people is provided in the home over two floors. The service is designed to meet the needs of older people. There were 56 people using the service at the time of our inspection.

A registered manager was in post and she was available during the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Sufficient numbers of staff were not on duty to meet people’s needs. Staff did not always safely manage identified risks to people. However, people felt safe in the home and staff knew how to identify potential signs of abuse. The premises were managed to keep people safe. Staff were recruited through safe recruitment practices. Safe medicines practices were followed.

People’s rights were not fully protected under the Mental Capacity Act 2005. However, staff received appropriate induction, training, supervision and appraisal. People received sufficient to eat and drink. External professionals were involved in people’s care as appropriate. People’s needs were met by the adaptation, design and decoration of the service.

Staff were kind and compassionate and knew people well. There was some evidence to show that people had been involved in the care planning process and improved documentation had been put in place to prompt staff to better involve people. Advocacy information was made available to people. People’s independence was promoted and visitors could visit without unnecessary restriction. We observed two instances where dignity was not fully respected but at all other times, staff treated people with respect and protected their dignity and privacy.

People did not always receive personalised care that was responsive to their needs. Activities required improvement. Care records did not always contain sufficient information to support staff to meet people’s individual needs. However, a complaints process was in place and staff knew how to respond to complaints.

There were systems in place to monitor and improve the quality of the service provided, although they were not fully effective. People and their relatives were involved or had opportunities to be involved in the development of the service. Staff told us they would be confident in raising any concerns with the registered manager and that appropriate action would be taken.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We spoke with five people who used the service and the registered manager. We also looked at some of the records held in the service including the care plans for three people. We observed the support people who were receiving bed rest experienced.

We considered our inspection findings to answer questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found-

Is the service safe?

People had been cared for in an environment that was safe and clean. The manager had utilised information provided by a community based infection control specialist to improve the infection control systems and ensure they were fully compliant with safe practices. Equipment at the home had been well maintained and serviced regularly.

There were enough staff on duty to meet the needs of the people living at the home and the manager had taken immediate actions to allocate a member of staff to answer call bells in each of the three zones of the home to ensure response times improved.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place to ensure staff understood when an application should be made, and how to submit one.

Is the service effective?

People who used the service, that were able to express their views about their experience of the care they received, told us they were happy with their care. We spoke with three people, comments included, 'Yes, they look after me well, I have no worries.' Two relatives we spoke with also told us, 'The nurse always rings us and lets us know of changes, they are very good.'

These people had a range of opportunities to discuss what was important to them and could inform improvements in the way the home was run through suggestions, comment books and resident committee meetings.

We found that some people who used the service were unable to be involved in meetings or record their concerns due to their deteriorating health needs. These people, and their advocates, were not fully involved or consulted regularly about their care and support needs. As a result, these people could have experienced inconsistent care delivery which did not uphold their rights and dignity.

Is the service caring?

As part of our inspection process we observed the interactions between the staff and people residing at the home. We found staff caring and attentive. When assisting people to eat and drink they took time and showed patience and understanding.

Is the service responsive?

We found that information was made available to people who used the service and visitors to explain what to do if they had concerns and complaints. The manager worked hard to encourage feedback from people and improve the services provided.

Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded. However, we found that there was a lack of regular consultation with planning and reviewing people's health care and there was a risk that there may be delays in referrals to health services when changes in their health happened.

Is the service well-led?

Quality assurance processes were in place. The provider took account of complaints and comments to improve the service. The manager had gathered information about the safety and quality of their service from all relevant sources.

The manager gathered information about the risks to people's health, welfare and safety by auditing the systems in place and identifying areas for improvement. Not all identified improvements were monitored by the manager to ensure they were implemented and sustained.

When we visited we spoke with six people who used the service and observed the care of others. We found staff were working continuously to meet people's needs and there was often a delay in responding to people's requests for assistance. One person said, "It can be five minutes or it can be 50 minutes. It depends how busy they are." A visitor told us, "They just don't answer the call bells straightaway, because they are so busy."

We observed people sitting in wheelchairs in the dining room waiting for assistance to move back to their rooms or to the lounge. They said they had to wait a long time for staff to be available to take them.

We concluded that there were not enough staff to meet people's needs.

We looked specifically at the records of three people who had been prescribed creams and lotions. The care plans for these were clear about the assistance needed from care staff. We found that charts were available in the bedrooms for staff to complete, but staff told us they did not always remember to complete the chart after applying creams. One person confirmed that their cream was usually applied each morning and the condition had improved.

Following this inspection visit we contacted the provider's quality assurance manager for the area and they assured us in writing that systems to regularly check the records had been put in place immediately to ensure all records were fully maintained.

People that used the service were very pleased with the quality of meals and told us there was always a good choice. One person said, "They bring my meals to me in my room and there's always something I like." People could choose to eat in the dining rooms or in their own rooms.

Regular visitors to the home told us the premises were always kept very clean. We found staff were very aware of how important it was to follow the infection control policy and this helped to protect people from the risk of infection.

People who used the service and some of their relatives told us they thought there were always enough staff available to assist when needed. One person said, "They come and help me when I use my buzzer even if I have to wait a bit sometimes."

A relative told us, "The care staff all do a very good job. They work hard and they pop in when I'm here to check all is well."

Some people were aware of the information about their care in files in their own rooms. One relative told us they check what my (relative) has had to eat and I know they write down when they have been in." We found appropriate records were maintained regarding staffing and the maintenance of the premises, but not all information was available about how the staff should meet people's individual needs.