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Archived: Berkeley House

Overall: Requires improvement read more about inspection ratings

Berkeley House, 18-24 High Street, Edgware, Middlesex, HA8 7RP 07950 461139

Provided and run by:
Destiny Nursing & Care Agency Ltd

Important: This service is now registered at a different address - see new profile

Latest inspection summary

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Background to this inspection

Updated 11 April 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was an announced inspection that took place on 28 September 2016. 48 hours’ notice of the inspection was given because the service is a domiciliary care agency and the registered manager may have been out of the office supporting staff or providing care. We wanted to be sure that they would be present.

Before the inspection, we checked any notifications made to us by the provider, safeguarding alerts raised about people using the service, and information we held on our database about the service and provider. This included the Provider Information Return, a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

There were 14 people receiving regulated activities from the service, and 21 care staff, at the time of our inspection. The inspection was carried out by one inspector. During our visit to the office premises we spoke with the registered manager and office manager. We looked at the care files of the four people using the service along with the personnel files of five staff members and various other records relating to the care delivery and management of the service such as the staffing roster, training records and stakeholder surveys. The registered manager also sent us further information on request following the inspection visit.

Following the office visit, we arranged to visit two people using the service with the permission of their closest representative whom we spoke with as the involved people’s complex needs meant we could not gain their views on the service. We also spoke with one of the agency’s care staff and checked records during these visits. We also gained feedback from stakeholders by phone and email. In total, we gained the views of the family representatives of six people using the service, five community healthcare professionals, and two care staff.

Overall inspection

Requires improvement

Updated 11 April 2017

This was an announced inspection that took place on 28 September 2016. It was the first inspection of this agency at this location, after the agency had moved addresses locally.

Berkeley House is a homecare agency based in Barnet that provides services to people of any age, including those with dementia, mental health needs, or physical disabilities. At the time of this announced inspection, they were providing personal care and support to 14 people living in their own homes.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission 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.

Representatives of people using the service, and most community healthcare professionals, provided good feedback about the service and its impact on people’s quality of life. Staff were described as caring, careful and knowledgeable. People usually received the same staff, which helped positive relationships to develop. We found that the service was caring and responsive.

However, we found some significant concerns about how the service was operated that particularly undermined people’s ongoing safety. Risk management processes were not comprehensive. They did not ensure that all reasonable actions were taken to minimise risks to people using the service, including in relation to medicines management, checking for a safe care environment, and supporting to move people safely. Whilst efforts were made to address people’s needs in practice, people’s care plans did not consistently address all their support needs and sometimes were not set up by the agency. This all had potential to undermine safe care practices.

The provider failed to promptly notify us of significant injuries to two people whilst receiving care from the service, which prevented us from monitoring the service effectively. One of these injuries resulted in hospital admission.

Criminal record checks and appropriate references were not in place for some newer staff before they started working in people’s homes, which did not ensure people’s safety.

There were few recorded governance systems in place, and so we identified shortfalls that the management team and the provider had not recognised or addressed.

However, the service worked well in partnership with other agencies, and provided staff with a positive and supportive culture, to help ensure people received good care. The service provided good support for people’s health, nutritional and end-of-life needs. We found instances where the service had taken practical action to protect people. Attention was also paid to upholding good standards of infection control.

There were overall three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report. However, full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.