The Berrys Carehome

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 people were not always safe and there was an increased risk that people could be harmed. The provider was in breach of the legal regulations in relation to safe care and treatment, premises and equipment and staffing.

This service scored 50 (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 learning and developing the service. There was not a culture in the service to address people’s changing needs and learning from events and incidents. The manager told us there had not been any incidents or accidents, except for 1 where a person shut their finger in the door. Whilst this had been recorded, we were not assured that all incidents such as falls noted in people’s care plans were being recorded as incidents and therefore any themes and trends analysed to drive improvement. Partners were not always made aware of safety events in the service.

The provider lacked insight into developing the service as there was not a focus on driving improvement. There was a lack of awareness of the concerns we found such as fire safety and the disrepair in the premises which had not been raised or addressed by the provider or staff and measures taken to learn and develop the service.

Staff gave us examples of how people had been included in discussions about incidents they had experienced so they could learn how they could prevent it from happening again. They worked with people to support them to learn and develop their skills in keeping safe.

The provider worked with healthcare partners to develop and maintain systems of care, in which people’s wellbeing was managed or monitored. For example, the provider had agreed an arrangement with a person’s GP for them to access the surgery when they needed to without an appointment. This had worked well to minimise the person’s distress and anxiety when accessing the surgery.

Key information about a person’s background had been obtained when they moved to The Berrys Carehome to understand their needs, backgrounds and histories. People had been supported to transition to the service in sometimes difficult circumstances. The provider had been proactive in ensuring people settled in and a plan of care was developed with the person, their relatives, staff and professionals.

Systems and policies were in place to reduce the risk of people being abused and harmed. The manager was aware of the process they should take to report any safeguarding concerns to the local authority and to CQC.

People and their relatives told us they felt safe living at the service. A person told us, “I am okay here, staff help me with everything.” A family member said, “I can’t fault the care at The Berrys, and I know [relative] is safe and well looked after.”People were supported to understand what keeping safe meant, including sexual safety. They were encouraged and empowered to raise any concerns they had and were appropriately supported if they felt unsafe.

Staff had completed appropriate levels of safeguarding training for their roles and understood their responsibility to report any concerns. A staff member told us, “I have never raised any, but I know if I have concerns where to report them and how to make sure it is addressed.” Staff were aware of people’s rights if they were deprived of their liberty and needed support in the community.

Risks relating to people were assessed but were not managed appropriately. For example, risks to one person whose needs were declining due to age and mobility, had not been escalated to relevant agencies for risks to their health and safety to be assessed by professionals. We raised this with the provider and action was taken during our assessment to make the necessary referral.

Risk assessments we saw were out of date and lacked clear and robust information about people’s needs such as their seizures, mobility and capacity. Some care plans had not been updated from the initial review, and it was difficult to know their current needs, likes and preferences. Care plans were not organised in a way to help locate information easily which made them difficult to read and to understand how care should be provided to the person.

Staff knew people well; they were able to tell us about associated risks to people and how they managed those risks. People were supported to keep themselves safe and felt confident staff knew how to support them to mitigate any risks identified. There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care. Some risks to people were carefully managed to alleviate distress and anxiety.

When people communicated their needs, emotions or distress, they were supported, and staff could manage this in a positive way that protected their rights and dignity. Appropriate strategies were used to minimise the need for restrictive interventions. The manager was able to provide examples of how they supported people to manage risks to their health and safety and in the community.

Relatives felt staff were competent in responding well to people who communicated a need, emotion or distress. A family member told us, “My [relative’s] needs present staff with multiple, and often changing challenges. The Berrys record of looking after [relative] has been good.”

The provider had not taken people’s health and safety needs into account regarding fire safety systems. Effective arrangements were not in place to monitor the safety of the premises and equipment to keep people safe. Fire evacuation procedures were not robust. We saw evidence that two fire drills had been undertaken in the daytime and did not identify clear details of the evacuation procedure such as how long it took, exit routes, where the meeting point was and whether one staff member could manage an evacuation alone. The provider had not undertaken a nighttime fire drill to ensure staff were able to adequately and safely evacuate people from the building in the event of a fire at night.

Staff had undertaken fire safety training in the past year. The care manager told us, “Even though drills are usually held in the day, all staff, whether they work a day or night shift receive fire safety training. This ensures that every member of staff is fully prepared to respond to an emergency, regardless of the time it occurs.” However, we were not assured this had been tried and tested appropriately.

People’s personal emergency evacuation plans [PEEP] did not contain comprehensive and up to date information about their needs and any risks associated with evacuating the building in the event of an emergency. The PEEP’s lacked information about where their bedrooms were located, where the safety meeting point was and one lacked guidance for staff to support a person with their mobility care needs such as getting out of bed and accessing the stairs in case of an emergency. People, staff and fire emergency personnel were at risk of harm from the lack of up-to-date and accurate information about people’s needs in the PEEP’s.

The provider did not always consider and control potential risks in the premises. The tumble dryer was not well maintained as it was housed outside in a dirty shed. The provider acted, and a new shed was installed during our assessment. In the downstairs toilet there was an unguarded rusty radiator with a sharp edge which could potentially harm someone which had gone unnoticed.

There were no curtains in the lounge and old staff information was placed on a notice board which did not promote a homely atmosphere in the home. All areas of the premises needed redecoration due to wear and tear such as the walls, doors and skirting boards. Corridors were dark with lack of appropriate lighting. The garden was not well maintained for people to enjoy. Washed clothes were hung over the washing line and not pegged up. The provider did not currently have a renovation plan for ongoing works. The care manager told us this would be actioned before December 2025.

We could not be assured that there were sufficient staff available to support people. The service was managed by the registered manager, a care manager (who was also the registered manager at another service) and a team of 5 staff. The care manager told us they were fully staffed, with staffing arrangements being 1 staff member on a day shift from 8am to 8pm and 1 staff member on the night shift from 8pm to 8am. We were provided with the rotas from 13 to 26 July 2025 which confirmed this arrangement.

Staffing arrangements had not considered people’s needs. A dependency assessment had not been undertaken to ascertain the correct number of staff needed to meet the needs of people using the service. For one person who was at risk at burning themselves it was noted, “Staff should be with them when they access the kitchen.” The downstairs area of the service was open plan, with easy access to the kitchen and all appliances. Therefore, with only 1 staff member on duty, people could be at potential risk if not supervised in areas of the service identified as a risk.

There were not suitable staffing arrangements in place when people wanted access to opportunities such as to go out shopping, activities or health appointments with the support of staff. We requested evidence of staff rotas to show where and when staff had been on duty to support people. The care manager responded, “We arrange community access with the support of care staff, the manager, or the care manager, ensuring everyone has opportunities for inclusion and engagement.” Whilst people’s records showed they had been out into the community at different times within a month, there was no evidence provided to us of staff being on duty at these times to provide the support people needed.

People experienced continuity of care, for example being supported by a regular staff team, and care being delivered through an agreed routine.Staff received training appropriate and relevant to their role and their competency to manage and administer medicines was assessed. Training was refreshed at regular intervals to maintain knowledge and skills in line with best practice. We saw a practical course in moving and handling people had been booked for staff. A staff member said, “We always have regular checks on every aspect and get training for refreshers, which is always encouraging and a confidence booster.” Staff were supported in their role. This included induction, supervision, appraisal and support to develop their skills and qualifications.

The provider had a recruitment process in place. The recruitment files we viewed included an application form, details of any gaps in a person’s employment, pre-employment checks such as references and disclosure and barring service checks (DBS). This helps employers make safe recruitment choices. The provider did not always obtain a reference from a previous employer for a staff member. We discussed the reasons for this, and a satisfactory explanation was provided.

The provider did not always audit their infection prevention and control procedures effectively. During the site visit, we found the downstairs toilet (used by people, staff and visitors) not clean around the sink area, a dirty bin, no hand towels to dry hands and watered down hand sanitiser. A small radiator was rusted and dirty. Paint was peeling from the walls, skirting boards were marked and dirty and the stair rail was tacky to the touch with ingrained dirt.

We discussed with the care manager our findings on the site visit. They told us daily, weekly and monthly audits were in place, completed by staff and evidence of these checklists were provided. However, despite these checks and audits the provider had not found the concerns we found. As a result, people were not always living in a safe, hygienic and well-maintained place.

Staff had access to personal protective equipment (PPE) and confirmed they had received training around infection prevention and control. The provider had infection prevention and control policies and procedures in place but due to the condition of the premises this was difficult to maintain effectively. Staff understand the importance of food safety, including hygiene, when preparing or handling food. They followed the required standards and practice.

Staff involved people as much as possible in the cleaning of the shared areas of the service and supported them in cleaning their own bedrooms. Fridge and freezer and cooked food temperatures were monitored. The dining table was cleaned and tidied after meals along with the kitchen.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.The locked medicine cabinet was situated in the staff office. A staff list of signatures was available so staff would know who had signed the medicine administration records (MAR). Temperatures of the room were recorded and a fan in place for hot weather.

Most people had their medicines in the morning and evenings. Prescriptions were ordered online and then staff went to collect them. All information was contained within the medicines records, including topical creams, photos, dates of birth, and protocols for medicines prescribed ‘as and when’ needed. The MAR were all correctly completed and signed, with all medicines, dose, times given and if refused, this was recorded. There were no errors reported. For one person we saw ongoing discussions and oversight by the GP which supported the staff and person with their medicines to keep them safe and well. One person used a paraffin based emollient cream. We saw a fire risk assessment and policy for use of emollients in place.

Staff had been trained in medicines administration. We saw their competency had been checked by the registered manager. A staff member said, “I am very confident in administering medicines. We got training plus competency checks, and clear protocols in place”.The provider was following their policy and procedures for the safe administration and management of medicines.