Berrycroft Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of two legal regulations in relation to safe staffing, the safety of people’s medicines and individual risk management.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Staff did not always listen to concerns about safety. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents were recorded, and analysis was completed by the registered manager. However, we were not assured that thorough investigations were carried out to address repeat concerns. It was not clear that people always had their care plans and risk assessments reviewed after an incident to mitigate the risk and reduce the risk of recurrence. The registered manager told us there were flash meetings with department leads at 11am each day and these meetings were recorded. People’s immediate needs were discussed so that those staff present were aware. We were not assured of the frequency of these meetings as only 8 of these meetings had been recorded for the previous 4 weeks.However, after we had issued our draft report, we were informed that flash meetings were only held on a risk-responsive basis and were not held daily.

We reviewed the meetings file and found a recent resident meeting which noted that people had raised concerns about night staff. Recorded comments included: ‘Night staff are not approachable…told to get back into bed and they felt like a naughty child.’ and ‘Residents have said on multiple occasions there aren’t enough night staff, and they are too busy to make them a hot drink. Other residents feel like they can’t ask as they are scared to.’ We did not find any evidence that action had been taken to address and rectify these concerns.

Staff told us they had reported concerns about insufficient staffing levels, including reporting in writing to the management team. One staff member told us, “There’s absolutely not enough staff and people are at risk.” However, staff told us their staffing levels concerns were not responded to or addressed, despite regularly reporting their concerns about people’s safety to management.

Not all concerns found at our previous inspections had been fully addressed. For example, we found continuing safety concerns regarding safe medicines management and individual risk management.

The provider worked with people and healthcare partners to establish and maintain safe systems of care; however, they did not always manage and monitor people’s needs safely. They made sure there was continuity of care, including when people moved between different services.

The registered manager told us about their close working relationships with other services including the local GP service, district nurse teams and mental health professionals. Records demonstrated referrals were made to services where this was needed and people received medical attention when necessary. However, we found advice given by healthcare professionals was not always transcribed accurately into care plans and therefore, not effectively followed by staff to ensure safe and good care for people. For example, we found one instance where a care plan that had been devised by a healthcare professional was not being followed in relation to their modified diet and fluids. We found some shortfalls in how care was provided to people who had fragile skin and were at risk of developing pressure injuries. This included a lack of guidance for staff on how to manage people’s skin conditions and plans and records in relation to repositioning to prevent skin breakdown were inconsistent.

People and their relatives told us they were kept updated and informed about their loved one’s care and they were assured medical attention would be sought when needed. One relative told us, “A doctor is available if needed and [Name] has their hair and feet done, and the district nurse comes to check on them as well.” Another relative told us, “[Name] had a fall the other night. They [staff] informed me straightaway, they phoned an ambulance, and [Name] went for a check-up.” One person told us, “If I don’t feel well, I know they [staff] will come and help straightaway.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People and their relatives told us they felt they were safe living at Berrycroft Manor. One relative told us, “I can also see how well the staff treat [Name]. I know [Name] is in safe hands.” Another relative told us, “[Name] is very safe here. The staff are superb. I cannot fault anything they do for [Name].” One person told us, “I feel very safe here. I’ve been to other places before this, and this is by far the best I’ve been in.”

The registered manager told us they followed local authority governance arrangements for reporting concerns and for notifying CQC of abuse or allegations of abuse and we reviewed evidence of this practice during our site visits. The management team and staff were knowledgeable about recognising and responding to safeguarding concerns and were keen to ensure people were kept safe. Staff received training in safeguarding and understood the process of escalating concerns in a timely way.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had their needs and risks assessed and had care plans in place. However, we found concerns with some people’s individual risk management, for example, monitoring charts were not always clear and care plans and risk assessments were not always reviewed and updated when incidents had occurred. Care plans and risk assessments were not always in place for specific, individual risks or contained the correct information to provide safe care. Where people required additional monitoring actions, we found records did not always demonstrate these risk management actions were being completed in line with their assessed needs.

Staff were kind, caring and reassuring with people and we had no concerns about personal interactions; however, we observed a small number of poor manual handling techniques. We reviewed the care plans of 2 people, whom we had observed to receive poor manual handling assistance, and found their care plans did not include information on how to safely assist them to move. This meant people were at the risk of harm from unsafe moving and handling practices as there was a lack of detailed directions to guide staff. We reported our concerns to the registered manager who told us they would investigate our concerns. We found many people did not have access to a call bell or did not have a call bell cable in situ, and there was a high usage of sensor mats for people to alert staff to movement. We found sensor mats were not always effectively placed and we were not assured of their appropriate use for all people who were at risk of falls. For example, one person told us they did not want the sensor mat in their room.

We found one person had their risk of choking assessed by a speech and language therapist (SALT). The assessment’s detailed information on how to safely manage this choking risk had not been transferred fully to the person’s care records and we found they had been placed at the risk of harm from not receiving food and drink in line with their SALT assessment. We also found 2 people, who used equipment for continence care, had their equipment placed in an unsafe position and this placed them at the risk of harm. We reported our concerns to the registered manager, who told us they would rectify our concerns immediately.

There was limited evidence that people and families were involved in making decisions in relation to the management of risk. We reviewed a sample of people’s records and did not see evidence that people or their families had been involved in these reviews and there was no record of any input or feedback. However, one staff member told us a lot of residents lack mental capacity to be involved, and staff try to speak to their family for input. They told us sometimes family choose not to be involved, but they do try and involve them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We carried out a tour of the home at various times and on the first morning of our site visits we identified some areas of the home were not secured and may pose risk of harm for some people. We found some medication rooms were unlocked and some unsafe items, such as unlocked medicine cabinets and trolleys were easily accessible. Cupboards in the kitchenette areas on some units were unsecured and contained chemicals and we found unsecured drink thickener on 3 units. Drink thickener is a high risk choking hazard for some people. Other areas that could pose a safety risk were also accessible; these were the sluice rooms and the electrical mains room. We reported our concerns to the registered manager, and these areas of risk were immediately rectified and made safe.

People’s bedrooms were clean and tidy, and very personalised with nice furniture and bedding. The building, garden and décor were all in good condition. However, we noted there were some malodours in different parts of the building. We reported this to the registered manager, who told us this was due to the sluice area and could not be rectified.However, after we had issued our draft report, we were informed that whilst odours were present at times, actions were taken to reduce their impact.

Health and safety checks were in place, and the maintenance man kept good, auditable records in easy to reference files.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support and training. There was not enough staff to ensure they worked well together to provide safe care that met people’s individual needs.

Berrycroft Manor has 2 units on each of its 3 floors which are separated by a keypad-locked door. Each unit has its own lounge/dining room, bathrooms, clinic room, sluice and several bedrooms. We found each unit had a mixture of people with dementia and people without dementia. On the first site visit, the inspection team arrived early and were unable to find any staff members present on either of the 2 units of the second floor. The registered manager later told us there was an agency staff member on one of the second floor units providing care to a person in their room and therefore, not visible to us.

We reviewed the staffing levels and staff rotas for the last 4 weeks and found there was only 1 staff member covering each of the 6 units and 1 senior staff member floating for all units in the home during the night shift (8pm to 8am). We also found that some night staff finished at 7am when day shift did not start until 8 am. Therefore, there were occasions where there were only 5 staff on duty to cover 6 units over 3 floors between 7am and 8am. We noted multiple instances during our site visits where there were no staff present in communal areas. Staff told us there was not enough staff, especially at night, where they told us it was impossible to cover the home with the number of staff on duty, especially when agency staff were used, as the agency staff needed constant direction.

Some staff told us the insufficient staffing level problem was exacerbated by the use of agency staff, especially those agency staff with poor English language skills. One staff member told us, “Agency staff; they are okay but, in the past, we had some that may as well not be here, and it makes it harder to do the job. They don’t shadow enough before they’re on their own. There’s a language barrier; it can be very difficult for staff and residents. There’s a lot of residents that are hard of hearing and find it difficult even when the staff are English, so they find it very difficult. Some of them [agency staff] just don’t talk to the residents.” We noted several occasions during our site visits where we, and people living at the home, experienced a language barrier with agency staff. We received mixed feedback from people and relatives about agency staff. One relative told us, “When I come, it’s always the same staff mainly, and I can have a laugh and a joke with them. Even the agency who are on are okay.” However, one person told us, “Agency [staff] are a waste of time because they don’t know what they are doing.”

Throughout the site visits, we noted call bells were ringing for long periods and on two occasions, we activated a call bell on behalf a person who required staff assistance and we waited 25 minutes on 1 occasion and 15 minutes on the other occasion before seeking further assistance as no staff responded to the call bell. We reviewed the call bell response analysis report from the registered manager and found the average call bell response time was 25 minutes. This meant people were not always receiving safe and timely care to meet their needs. We received mixed feedback from people about responding to calls for assistance; one person told us, “In a morning, I just shout out or wait for them [staff] to come and help, I don’t think I have to wait that long.” However, another person told us, “At certain times I press the buzzer, it can be hours before they come, and on occasion, the day staff will say it can wait till the night staff are on, or vice versa.”

We had concerns about the efficacy of staff training due to the large amount of online training some staff were completing in one day. On review of the staff rotas, we could see new staff members were working unsupervised on night shifts before they had completed their mandatory training programme. There was no condition-specific training, such as, skin integrity and diabetes, or more in-depth dementia training, despite people living at the home with these conditions. One staff member told us the dementia training took just 1 or 2 hours, and they would prefer some good training that would benefit staff as “new starters don’t have clue about dementia.” We noted only a very small number of staff had fully completed the mandatory training relating to people with a learning disability and autism and this is not in line with the provider’s regulatory requirements.

We found safe recruitment checks were mostly in place. We found a small number of missing pieces of recruitment information that were rectified when we reported them to the registered manager. We found the home used agency staff on a regular basis; however, we were not assured that the registered manager had assured themselves that all agency staff were suitably experienced and competent through a robust induction process or competency checks. The registered manager later told us they would be implementing an induction process for agency staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the home to be clean, and we noted cleaning staff working hard throughout our 2 days of site visits. However, we found some kitchenette areas on units required some refurbishment and were not always fully clean. We reported this to the registered manager. People and their relatives did not raise any concerns with us about infection control or cleanliness. One relative told us, “I think the place is very clean and [Name] has a nice room.”

Staff received training on infection prevention and control, and we saw staff were working in line with good infection control practices, including the use of personal protective equipment (PPE) where necessary.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were not always stored securely; on day 1 of our assessment, we found a number of concerns about the security of medicines, on day 2 we saw that immediate action had been taken to make improvements. We found similar concerns during our September 2024 assessment. Medicines records were generally signed and completed. There was an effective stock management system in place to ensure that people did not run out of medicines. The home’s medicines administration system had systems for managing and auditing medicines. One audit focussed on medicines stock adjustments that had been made but it was not clear from these audits why stock was adjusted so we could not always be sure if medicines were being administered as prescribed.

We saw two medicines that required to be given 4 hours apart to prevent overdosing were not always given the required 4 hours apart. Staff had overridden standard warnings from the electronic medicines system and administered them too soon. After the inspection the manager told us some actions had been taken to help prevent this happening again. Recent changes from paper recording to electronic recording for the management of fluid thickeners, used for people with choking risks, had not been effective as electronic records did not always reflect what thickness the fluids had been thickened to.

We looked at supporting documentation for medicines such as care plans and ‘when required’ medicines. These had been improved since the last the assessment including a thorough detailed summary of people’s medicines and what they were prescribed for. However, , the records did not always reflect the involvement of GPs, family members, advocates or pharmacy professionals in the best interest decision making for covert medicines. Topical medicines such as creams were available, and records showed these were being applied. Medicine patches were being applied safely, and the site of application was being rotated properly. People that were living with Parkinson’s disease were given their medicines on time and this was audited by managers for assurance. Temperatures were being recorded for medicines rooms and fridges to help make sure medicines were being stored safely. Controlled drugs were stored and recorded safely. Records showed that relevant staff had all received medicines competency assessments and medicines training.