26 July 2022
During an inspection looking at part of the service
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.