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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

A number of different meetings had taken place at the home. We found staff meetings were not frequent, and staff told us they would benefit from more meetings. Staff told us they had concerns about the delivery of safe and effective care due to insufficient staffing levels. Staff were open and described how they wanted to provide better care for people but did not have the time to spend time with them. Staff told us they had explained their concerns to management, but improvements had not been made. The registered manager told us the home had a family culture, and they have a good staff team who have close relationships with the people living at the home.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

The registered manager was supported by 2 deputy managers and a team of senior care workers. Support was provided to the management team by the area manager who visited the home regularly.

We were not assured that the management team were visible around the home and actively engaging with people and staff as we received mixed feedback from staff, and people and their relatives, about the management team. One relative told us, “Before [Name] came here, the manager came to see [Name] in hospital and sorted everything out for us together with social services. I can go to speak to them anytime and they will listen.” One person commented, “[Name] is the manager, they explained why I am here, and they ask me if I’m alright when I see them.” However, one person told us, “Never see the manager, where are they?” and another person told us, “I never see [Name] and don’t have much to do with them.”

People did not always feel they could speak up and that their voice would be heard.

Although there were systems in place for people to feedback about their care and for staff to raise any concerns or suggestions, we found little evidence to support that people’s voices were heard, and actions taken as a result of feedback. We saw that people living at the home had regular meetings with the activity staff, where they were they could feedback their thoughts and feelings about the home. It was unclear how this feedback was reviewed and actioned by management and the provider. For example, concerns were raised by people living at the home about the care from night staff in September 2025; it was noted that one person had said they had some terrible experiences with night staff where they had been rushed and not cared for properly. We found these concerns had already been raised at a prior meeting in August 2025 by several people. These concerns related to unapproachable staff; not enough night staff as they were too busy to provide care, and one person commented that they had been spoken to unkindly.

Staff received supervision and the registered manager told us they had an open door policy where staff could come and talk about anything. However, we received mixed feedback from staff about their freedom to speak up. Staff told us they spoke up and raised concerns when they felt people were at risk from poor care delivery, but they often felt that they were not heard. Staff told us they had raised concerns with the registered manager but did not feel their concerns were always acknowledged or acted upon. One staff member told us they had raised concerns about staffing levels and told us the management only looked at numbers of people on the units and did not consider the high dependencies of the people they cared for.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had a diverse workforce. There was an equality and diversity policy in place and staff had received training.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Although audits had been carried out at the home and governance processes for oversight were in place, they had not always identified concerns or actioned concerns when they had been identified. For example, despite audits in place, we found concerns relating to the safety of the environment and shortfalls in timely and safe and care delivery, such as, call bell response times, manual handling techniques and unsafe positioning of continence equipment.

We found some concerns relating to accuracy of people’s care records that had not been identified and actioned through management audits. For example, we found conflicting information in some people’s care plans; for example, one person’s care plan showed a recent photograph of moisture damaged skin, but care plans had not been updated to reflect and manage this risk.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager worked with partner agencies and the local authority confirmed they had no concerns about the home prior to our inspection. The home worked with healthcare professionals and had previously been involved in a project to improve the experiences of people receiving end of life care, which led to one staff member from Berrycroft Manor receiving a special recognition award for their work in this area.

The registered manager told us the local church visits every other week, a nursery also visits every other week, and local school children come to the home each Friday. They also told us of their future plans to implement a dementia café for the people living at Berrycroft Manor and support for people with dementia and their families in the local community. Several charity fundraising events also take place at the home where the charity of choice is decided by people living at the home.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The recording and reporting of accidents, incidents and safeguardings was in place. Periodic detailed analysis was also in place; however, we found this could be further improved by demonstrating in detail what actions had been taken to mitigate further risks.

There were IT systems in place to identify to the registered manager when incidents occurred so they could be reviewed. We saw that the registered manager had conducted some internal investigations when people had been harmed. On our review of the home’s incident analysis for the previous 3-month period, it was noted that the majority of incidents occurred at night. We also noted one person had experienced 18 incidents and another person had experienced 14 incidents over this period; however, it was unclear what actions had been taken to further explore this theme and to mitigate the risk of incidents at night and people experiencing multiple incidents.

The registered manager told us they conducted an annual survey of people and their relative’s opinions on the quality of care provision at Berrycroft Manor. The responses from the last survey were very positive about the care delivery but people said they would like more activities and therefore, improvements were made to the activities provision based on what people said they wanted.