Berwick Grange

Berwick Grange is a residential care home providing personal and nursing care to up to 52 people. The service provides support to older people, some of who may be living with dementia. At the time of our inspection there were 39 people using the service.

The care home is a large purpose-built building with bedrooms and communal spaces across 3 separate units. Two of units were for people who required nursing care and were living with more advanced dementia.

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

Staff knew the people they supported well and how to meet their needs. However, there was a heavy reliance on agency staff which impacted on the quality of care provided. Staff were safely recruited but staffing levels and deployment was not always sufficient to meet people’s needs.

Care plans and risk assessments were not always effective in outlining people’s needs and how best to meet these. Staff told us that at times agency staff lacked understanding of people which increased their distress.

Audits and oversight from the provider had been ineffective in monitoring and addressing concerns in the service. Where action was identified this was not always taken in a timely manner. A service development plan had recently been implemented and progress was being made to improve the environment and outcomes for people at the service.

Staff understood their responsibilities around safeguarding and documenting accidents and incidents. The reported accidents and incidents had not always been effectively managed by leaders in the service. The provider recognised these shortfalls and had been working with the local authority to address these.

Medicines were managed safely and in line with people’s preferences.

The manager was working collaboratively with staff and other agencies to make the required improvements. Staff were knowledgeable and passionate about the people they supported and were keen to improve the service.

Staff had confidence in the changes being made and felt able to be involved. Families spoke highly of the care their relatives received from staff and welcomed the reintroduction of resident meetings.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Rating at last inspection

The last rating for this service was good (published 10 June 2019).

At our last inspection we recommended that the provider reviews best practice guidance when using agency staff and take action to update their practice accordingly. At this inspection we found the provider had implemented practice changes around use of agency staff and information was readily available.

Why we inspected

We received concerns in relation to staffing and management of risk. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Berwick Grange on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to staffing, safe care and treatment and good governance at this inspection.

We have made a recommendation about the Mental Capacity Act.

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.

We found the following examples of good practice.

Effective systems were in place to ensure staff and visitors followed government guidelines for wearing Personal Protective Equipment (PPE). Screening questions and a temperature check were standard requirements for all visitors. Staff supervised all essential visitors to ensure social distancing and IPC guidelines were followed.

People were supported to maintain contact with their relatives in different ways including screened visits and video calls. The service had outside facilities for garden visits when appropriate.

All staff were trained in safe IPC practices. We observed staff wearing appropriate PPE and plentiful supplies were available at designated stations around the home.

People admitted to the service were supported following government guidance on managing new admissions during the COVID-19 pandemic. A regular programme of testing for COVID-19 was in place for staff and people who lived in the service. There had been a good uptake of residents receiving the COVID-19 vaccine.

Enhanced cleaning took place daily. The environment was clean and hygienic.

The service had plans in place and knew how to respond to an outbreak of infection to ensure the safety of people and staff.

Berwick Grange is a care home providing personal and nursing care to 48 people aged 65 and over at the time of the inspection, some of whom were living with dementia. The service can support up to 52 people.

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

The provider had made improvements following the last inspection. Quality assurance systems were in place to monitor safety and quality across the service. Governance processes had not always identified shortfalls we found with records during inspection. The provider was working to address points identified as part of a dementia action plan and follow up their quality assurance checks. Work was ongoing to continue to make changes and embed new systems and practices.

People’s safety was assessed, supported and monitored. The deployment of staff was considered to ensure additional support was available at busier times of the day to ensure people received support.

We made a recommendation about the use of agency staff.

People were supported by trained staff, who used their training in dementia care to inform their practice, including at mealtimes. The environment had been altered to suit the needs of people living with dementia, these improvements to indoor and outdoor spaces were ongoing.

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.

Staff provided warm, kind and compassionate care, which people responded positively to. Their privacy and dignity was respected.

People received person-centred, responsive care. The provider was working to improve the variety of activities on offer to stimulate and engage people.

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

Rating at last inspection and update

At the last inspection the service was rated requires improvement (published 26 April 2018) and there were two breaches of regulation. Following the last inspection, we asked the provider to complete 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 inspection based on the previous rating.

Follow up

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

Berwick Grange is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Berwick Grange offers both residential and nursing care for up to 52 older people and people living with dementia. Accommodation is provided over three floors, each of which has separate communal facilities. Residential care is provided on the ground floor and nursing care is provided on the upper floors. At the time of our inspection there were 52 people living at Berwick Grange, 32 of whom required nursing care.

There was a registered manager in post. A registered manager is a person who has registered with the 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. The registered manager was available and assisted on both days of the inspection.

At the last inspection on 22 December 2015, the home was rated Good. At this inspection we found standards had not been maintained and required improvement. This is the first time the service has been rated Requires Improvement.

We found breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) of the Health and Social care Act 2008 (Regulated Activities) 2014.

Staff were not consistently following the provider's medicine policy and this meant people were at risk of not receiving their medicines safely. For example, medicines that required cold storage were not always stored at the correct temperature. Arrangements were not in place to ensure people’s topical medicines such as creams and ointments were well managed. There was limited specific written guidance for the use of ‘as required’ medicines to enable staff to provide a consistent approach to the administration of this type of medicine.

Risks to people were identified and assessed but care plans to reduce those risks and guide staff on how to manage specific risks were not always established. This meant people were at risk of receiving unsafe or inconsistent care.

Management systems were not always effective in identifying shortfalls in the quality of the service. Some records were not complete or well maintained and staff training was not fully embedded or supported by effective supervision and support. This had led to inconsistency in some areas of practice across the home.

Staff were recruited safely. Whilst there were enough staff on duty to care for people safely, the availability of staff sometimes impacted people’s care. This was identified as an area that needed to improve.

Staff had received training but our observations were that staff did not always apply their learning in practice. We saw staff who were confident, polite, well-mannered and accommodating however we also saw examples of inappropriate staff responses. We have made a recommendation about staff training on the subject of dementia.

People received a varied diet. However our observations were that some people did not always receive the consistent help they needed to eat their food. This was identified as an area of practice that needed to improve.

Arrangements were in place to maintain the cleanliness of the home but these were not always effective in practice. We found some areas, which required updating. We made a recommendation that the provider seeks further information about best practice in the use of colour and design within the environment to help people with dementia to orientate themselves in time and place. Environmental risks were assessed and monitored and the home and equipment were well maintained.

While we found that people did not always receive consistent care and support relatives spoke highly of the staff and said they were caring and compassionate. Relatives and volunteers were actively involved in people’s daily care and activities. We saw that this involvement, together with that of the home’s Chaplain and the music therapist promoted people’s spiritual needs and enhanced their sense of wellbeing. People had 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.

Staff supported people to access health care services and we saw that a range of health care professionals had contact with people at the home. One visiting health care professional told us that staff always made appropriate requests and complied with any guidance provided about people's health conditions.

You can see what action we told the provider to take at the back of the full version of the report.

On the day of the inspection we met people living in the service. People living at Berwick Grange had dementia type illnesses which made it difficult to communicate. During the day we spent time observing interactions with people and staff in three different communal areas in the home. We talked with three people about their experience of care and we spoke with the relatives of three people. We talked with eight staff and looked at records. We spoke with a visiting general practitioner (GP). Below is a summary of what we found.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. Relatives we spoke with told us that they believed their relatives were safe and well cared for. Staff had received training in safeguarding and understood how to safeguard the people they supported. Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents. This reduced the risk to people and helped the service to continually improve.

People were cared for in a service that was safe, clean and hygienic. Risk assessments were in place in individual care plans in relation to all activities of daily living. Training records demonstrated that the staff employed to work in the home had completed required training and were supported to develop skills and experience needed to provide care for people living at Berwick Grange. Staffing levels were appropriate to meet the needs of the service and were reviewed and adjusted to address any changing needs.

Is the service effective?

People told us that they were happy with the care they received. One person said, "I like it here, they're all nice here." Relatives told us that they believed the needs of their relatives were being met. One relative told us, "It's an amazing home, it's like a big family really." It was clear from what we saw and from speaking with staff that they understood people's individual care and support needs and they knew them well. People's health and care needs were assessed with them where this was possible and family members were also involved in discussion about their plans of care. Staff spoke with pride about the progress that individual people had made whilst they had been living in the service. Relatives we spoke with were able to describe specific benefits to the health and wellbeing of their relatives. One person told us, "They've been absolutely amazing, everybody's worked really hard."

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. We observed that people were supported to do things at their own pace and to be as independent as possible. People who used the service and their relatives were invited to complete an annual survey. Where shortfalls or concerns were raised, these were addressed. People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with their wishes. One member of staff told us, "I think we do a good job here, we work closely with families and we're open to finding out what people liked to do."

Is the service responsive?

People were regularly involved in a range of activities within the home and also occasional trips out. The home supported people to take part in activities and employed the services of a music therapist. People knew how to make a complaint if they were unhappy and two people we spoke with told us that they felt that they could talk with any of the staff if they had a concern or were worried about anything. We saw from care plans that the staff responded to changes in the support needs that people had. One staff member told us, "We assess people on so much of an individual basis."

Is the service well-led?

The service worked well with other agencies and services to ensure that people received their care in a joined up way. The service had a quality assurance system which included planned audits. Records seen by us showed that people who lived in the service, staff and relatives were asked for their views. Any identified shortfalls were addressed promptly and as a result the service was constantly improving. When we spoke with a GP they told us that they believed that the service was well run and was a positive place for people to live. Staff told us that they felt well supported by the manager.

Care plans and risk assessments were thorough and regularly updated. People themselves and families were involved in reviews and updating plans to ensure that the support people received was appropriate for them. We found that there was adequate nutrition provided and people were generally happy with the quality of the food provided. The staff were monitoring people's intake of food and drink appropriately.

The service made referrals to other services and organisations where needed and sought appropriate input from medical and health professionals when it was required. Staff were subject to a formal recruitment process and all the associated documentation was in place. A thorough induction process was completed by all staff.

There were thorough quality assurance systems in place which were followed by staff and there were opportunities for people who used the service, relatives and staff to feedback any issues or ideas. The service then acted on these appropriately.

People who used the service told us that they were happy living there, and relatives told us that they were very satisfied with the care and support their relatives received. One relative told us 'They are patient, kind, caring. My relative is well cared for'. One person who used the service told us 'I feel happy living here'. Another relative told us 'Staff are really happy for me to be involved and encourage it. I'm happy that he is here'.

We looked at the cleanliness of the home, and the suitability of the environment. It was noted that the home could be odorous at times, and there were no specific stimuli provided for people with dementia. Infection control guidelines were followed, and staff showed a good understanding of the ways to minimise risk of cross infection.

We looked at medication administration and found that people were given medication at appropriate times, and medication was stored, dispensed and disposed of appropriately. We also looked at records and documentation and found this to be comprehensive, person centred, regularly reviewed and up to date.