Archived: Berengrove Park Nursing Home

Updated 10 December 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. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by two inspectors.

Service and service type

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

There was no registered manager at the service. However, there was a manager in post who was in the process of registering with the Care Quality Commission. This means the provider was legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection including information from the local authority. We used the information the provider sent us in the 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. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with six people who used the service about their experience of the care provided. We spoke with nine members of staff including the provider, manager, nurse, senior care workers, care workers, the chef and kitchen assistant. We observed the interactions between staff and people in communal areas.

We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at one staff file in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

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

Updated 10 December 2021

About the service

Berengrove Park Nursing Home is a residential care home providing personal and nursing care to 35 older people at the time of the inspection. The service can support up to 39 people in one large adapted building.

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

People told us they felt safe and staff were attentive to their needs. They told us staff responded to their requests quickly.

There was a new manager in post who had started their registration with the Care Quality Commission (CQC). The manager had started to make improvements within the service, addressing shortfalls identified at previous inspections. Though improvements had been made they had not been embedded or sustained to show continued improvement.

We were somewhat assured people were protected from infection. Staff wore masks but these often slipped down below their nose. Handwashing liquid was not always available, and some equipment and furniture were not always clean. The manager acted immediately to rectify the concerns.

Potential risks to people’s health and welfare had been assessed. Some improvements had been made in the guidance provided for staff to mitigate the risk, though further improvement was still required. There was now a system in place to record and analyse any accidents or incidents to identify any patterns and trends.

Staff were recruited safely. There was now a tool in place to calculate how many staff were required to support people. There were enough staff to meet people’s needs, though people did not always have access to meaningful activities. The manager was aware this was an area of improvement.

The manager had implemented a comprehensive quality assurance system covering all areas of the service. Audits had been started and the results were being used as a baseline to measure future improvements against. Quality assurance survey had been completed and the results were positive.

Medicines were managed safely, when shortfalls were identified these had been rectified. Staff attended regular meetings to discuss people’s needs and their practice.

The provider had been open and transparent with people, relatives and staff about the previous inspection. The new manager had been introduced to families and they had the opportunity to discuss how the service would be moving forward.

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. There were systems in place to protect people from discrimination and abuse.

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.

The last rating for this service was Inadequate (published 27 September 2021) and there were multiple breaches of regulation.

This service has been in Special Measures since June 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

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

We reviewed the information we held about the service. There were breaches of regulation in the effective, caring and responsive domains but no new areas of concern were identified in these key questions. We therefore did not inspect them. However, we have followed up these breaches in the well led key question. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

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.

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

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.