Berrycroft Manor

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During the assessment we identified some concerns regarding risk, safeguarding and medication, although evidence was not provided to demonstrate this had been identified through the homes own governance systems. We recommend further improvements are made to governance systems to ensure any shortfalls are identified in a timely way. People said they knew the manager and that actions were taken if they raised any concerns. People said they were able to attend meetings to share their views and relatives received newsletters with updates about the home.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

It was unclear how the vision, values and strategy of the service had been developed with feedback from staff, people and partners. However, we received positive feedback about the registered manager and the overall leadership from staff, who told us they felt well supported, enjoyed their roles and felt there was a good culture at the location. One staff member told us, “[Registered manager name] is approachable and friendly, and always has the office door open.” The provider and registered manager certificates of registration and insurance certificates were clearly displayed in the entrance area.

The registered manager worked alongside other relevant professionals to meet people’s needs. The statement of purpose, service user guide and a copy of the previous CQC inspection report were on display for all to see. A statement of purpose is a legally required document which includes a standard set of information about a provider’s service. The registered manager’s office had a list of useful partner agency contact details for quick reference, and the office was well organised and tidy. There was evidence equality and diversity was promoted.

Most staff spoke positively about the service and told us they felt supported by managers and confident in raising any concerns. One staff member said, “It’s going well, and I have no concerns. It’s a good place to work and there is good teamwork amongst staff.” A second staff member told us, “The management are good, and they are lovely people; approachable and I can raise any concerns.”

There was an effective management structure in place and staff understood their roles and responsibilities; most staff were happy with the current staffing arrangements. People and relatives knew the registered manager and told us they frequently spoke to them. The registered manager carried out a number of checks and audits related to people’s experiences of care, for example, a dining experience audit on Rose unit undertaken in August 2024 had achieved a score 67% compliance and this was added to the Home Improvement Plan.

We received mixed feedback from staff regarding if they felt they were listened to by managers. One staff member told us, “You can go to managers who will sort anything; they are approachable.” However, we received negative feedback regarding night staffing, with some night staff feeling ‘their voices were never heard’, for example, a staff member told us they had been promised an extra staff member at night, but this had not been put into place. However, the registered manager told us plans were in place to recruit an additional night staff member.

There were processes in place for staff to speak up and a culture to encourage staff to do so. Information was available which supported staff in raising concerns if required, for example the provider had a whistleblowing and freedom to speak up policy, which staff had access to, and staff knew how to report any concerns. There were mechanisms in place for people and relatives to speak up and people and relatives told us the service was well led. One relative said, “The home is well run; very clean, the staff are lovely I have no complaints, I would give it 10/10 and I would recommend it to anyone.” One person told us, “I am as happy as I can be living here; I am comfortable and well looked after. I have met the managers, and they have been to see me; all the staff are very nice and chatty.”

Staff and leaders were representative of the local population. Most staff told us they felt valued by the provider. Staff told us they worked as a team and enjoyed working at the location. Throughout our on-site visit we saw there was a respectful and pleasant culture amongst staff and leaders. One staff member told us, “Managers are approachable and if you need to speak to them, you can. I feel supported and we have a good team.”

There were policies and procedures in place to support non-discriminatory and equitable staff recruitment. Processes were in place to support staff to carry out their roles to the best of their ability.

Policies and procedures were in place to support safe and effective care, and we received positive feedback from people and staff who told us they felt the level of care provided was good. Staff told us there were systems in place to record interventions such as staff supervisions, staff training and staff spot checks. However, we found gaps in some people’s care records regarding re-positioning, mental capacity assessments, risk assessments and medicines records. Staff and leaders engaged with people, communities and partners to share learning and make continuous improvements to the care provided.

There was evidence of quality assurance checks and monitoring of the service being undertaken by the registered manager to measure the quality of care delivered to people; however, these had not identified the issues we found during this on-site visit. Meetings were held with people using the service and their relatives; however, these were not frequent and regular. The meetings file we saw identified meetings with people had been held in August 2024, and February 2024, and meetings with relatives were held in January 2024 and February 2024, with no other records available for any dates prior to these. We saw the registered manager had suggested setting up a family support group and WhatsApp group at a meeting held with relatives; relatives had agreed this was a good idea and the registered manager had identified this in their action plan. Relatives had requested to see an overview of the Home Improvement plan, and the registered manager had agreed to investigate this request.

People and relatives spoke positively about the service and the care and support provided; they felt involved and were kept updated with any changes or issues. A relative told us, “When [person] first came to Berrycroft we talked through [person’s] needs and how they [staff] would provide the care; we were encouraged to personalise [person’s] bedroom, and we feel comfortable talking to the staff and management if we had any concerns.” We saw the registered manager had discussed the need for improvement in activity provision at meetings held with people and relatives. Relatives had access to an App which they could use to access care records.

The provider worked alongside partner agencies to help meet people’s care needs.

We did not receive any feedback from partners regarding this evidence category. We saw notes from meetings with district nurses held in January 2024 and June 2024, which reflected on a recent formal investigation after a person had passed away, which had gone well with good communication skills from staff. Communication, and how district nurses were required to report, and how they were supported at the home was also discussed. References to safeguarding identified good working relationships between district nurses and care staff.

Staff and leaders understood their responsibilities to work in partnership with external care professionals to ensure people received joined up care. Referral procedures were in place to ensure people received support from health care partners, such as district nurses and chiropodists. There was evidence in the care plans and daily notes the provider had liaised with various health professionals to ensure safe care and treatment for people living in the service, including Advocacy services.

There was evidence of learning being identified, when things had gone wrong. For example, staff and managers completed a reflective account following a medication error in April 2024, after which staff competencies in administering medicines were checked, a reminder of processes was sent to staff and a meeting was held with the pharmacy to discuss medication system issues. In another example, staff had completed a root cause analysis following a person sustaining a skin tear.

The provider had process and procedures in place to support learning and continuous improvement. Staff were encouraged staff to speak up with ideas for improvement and innovation. One staff member said, “I feel action would be taken if any bad practice was identified.” There was evidence staff were provided with opportunities for further training and development.