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Archived: Berkeley Court Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 29 April 2021

About the service

Berkeley Court is a residential care home providing personal and nursing care to 59 people aged 65 and over at the time of the inspection. The service can support up to 78 people. Care is provided across six units, within one purpose-built building.

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

We found an inconsistent approach to risk management. Risks were not always appropriately managed, relating to admissions, fire safety and following incidents. People received their medicines as prescribed although some improvements were required to ensure safe systems were in place relating to nutritional thickeners and blood thinners. We made a recommendation to ensure additional guidance was put in place for staff. Some limited incident analysis was undertaken but this needed to be more robust to examine whether there were any underlying themes and trends.

Systems to assess, monitor and improve the service needed to be made more robust to ensure that a consistent high-quality service was provided across all areas. Some care plans were out of date and training was not always up-to-date. An action plan was in place and additional management resources were available to help aid continuous improvement of the service. The service worked well with other organisations to provide stimulation and interaction for people who used the service. People and relatives said they were happy with the home and staff said they were happy to work there.

The home was clean, appropriate infection control procedures were in place and these were understood by staff. The premises were well maintained. There were enough staff to ensure people received prompt care and staff were recruited safely.

People and relatives provided good feedback about the service. They said care was provided in a safe way and said that it met individual needs. People said staff and management were kind, caring and communicated well with them.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 17 March 2020)

Why we inspected

The inspection was prompted in part by notification of two specific incidents following which two people using the service died. These incidents are subject to an investigation. As a result, this inspection did not examine the circumstances of the incidents. The information CQC received about the incident indicated concerns about the management of choking and medicines. We also had received concerns about the management of safeguarding risk. This inspection examined those risks.

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.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at 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. Some of these areas were known to the provider and other areas were added to the services action plan during our inspection by the management team.

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


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risk management, failure to

Inspection areas


Requires improvement

Updated 29 April 2021

The service was not always safe.

Details are in our safe findings below.



Updated 29 April 2021



Updated 29 April 2021



Updated 29 April 2021


Requires improvement

Updated 29 April 2021

The service was not always well-led,

Details are in our well-led findings below