The Berrys Carehome

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 there were shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The provider was in breach of the legal regulation in relation to good governance at the service.

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 and staff had a shared direction which was outlined in their statement of purpose. However, people were not always at the centre of this when decisions about their lives needed to be made such as any future planning and involvement in improvements to the service.

The provider and staff demonstrated a positive and compassionate culture that promoted trust and understanding between them and people using the service. We observed this during our assessment. A staff member said, “The Berrys Carehome cares about people’s wellbeing, improving services, and teamwork. Staff truly care about the people. This shared care makes it a nice place to work.”

The provider did not always have managers with the necessary skills and knowledge to lead effectively. We identified there were shortfalls in knowledge and skills in relation to managing health and safety, risk assessments and future care planning. These concerns had not been picked up by the provider.

The registered manager who was supported by the care manager, were compassionate and inclusive of working together with staff as a team. They were visible and available in the service. They were well thought of and known by the people, staff, family members and professionals. Staff told us, “Management ensure professionalism in our approach as they are very aware that it should not cross boundaries. They listen and act appropriately” and “[Names of leaders] are open-minded about new ideas and speak to us in a friendly and professional way.”

There was a culture of speaking up where staff actively raised their concerns and were supported, without fear of detriment. The provider was open to feedback and staff felt supported to speak up.

Staff felt there was a positive culture where they could speak up and were listened to by the provider. Staff were confident that their voices would be heard. A staff member told us, “Managers listen to ideas and concerns. I feel safe to speak up whenever.” Another staff member said, “I can speak up and share my views without any issues.”Team meetings were held to discuss the work at the service and staff had the opportunity to discuss their views and ideas. Staff received supervision meetings with the registered manager which were clearly recorded to show progress and appreciation of their work.

Staff members’ protected characteristics were considered to ensure their rights under the Equality Act 2010 did not have a negative impact on their wellbeing. The provider told us they were positive about employing disabled staff and made reasonable adjustments to support them to carry out their role. Staff had undertaken training in equality and diversity to support wider awareness in their role and responsibilities.

A process was in place to act on staff feedback and to promote fairness amongst the staff team. A staff member told us, “All staff are treated the same with respect.”

The provider did not have clear responsibilities, roles, systems of accountability or good governance in place. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider did not have effective management systems in place and failed to identify the concerns highlighted within this assessment.

The process for monitoring and auditing health and safety was not robust. Effective arrangements were not in place to monitor the safety of the premises and equipment. Fire evacuation drill records did not identify clear details of the evacuation to ensure staff were able to adequately and safely evacuate people from the building in the event of a fire at night. The fire evacuation procedures did not consider people’s aging and mobility care needs for those with an upstairs bedroom location, thereby increasing the risk to their safety in the event of an emergency.

The providers checks have not identified that people’s personal emergency evacuation plans [PEEP] were not comprehensive and did not contain information about the risks associated with evacuating the building. The PEEP lacked information and guidance for staff to support people who had mobility difficulties and needs relating to aging.

There was not effective monitoring to ensure care plans and risk assessments were detailed, accurate and fully reflective of people’s needs to identify, assess and mitigate risks to their safety and welfare. Risk assessments were not completed for all areas of risk relating to people and the premises to ensure people were kept safe. Risk assessments we saw were out of date and lacked clear and robust information about people’s needs. The provider had not been proactive in making the necessary arrangements and involving professionals to plan for people’s future needs and to address the current safety needs at the service. People’s capacity to make choices and decisions was not properly and accurately assessed and recorded.

People’s dependency levels had not been reviewed to ensure there were enough staff to support them. The rota arrangements were not managed effectively. We could not be assured there were enough staff on the rota for people to pursue their interests and hobbies and access the community when they wanted.

Governance processes were not effective in the oversight of the service. The provider did not have a plan in place for the continued improvement to people’s care and support or the needed renovations to the premises. Systems to ensure compliance with legislation and the providers internal governance arrangements were not comprehensive. We saw different recording tools used which did not support them to easily identify and analyse risks, outcomes and lessons learnt as a result. Quality audits were not sufficiently detailed and up to date to provide assurance that risks were being managed and improvements made. This resulted in people not receiving a standard of care and support they should expect.

As a result of the concerns, we found in relation to safe care and treatment, staffing and good governance, an organisational safeguard was raised by the local authority covering aspects of unsafe care practices.

The provider did not always work in partnership with key agencies to provide better outcomes for people. For example, referrals were not always made and advice requested when people’s needs changed to evidence a joined-up approach to care delivery. However, we did see examples of good practice which demonstrated ongoing relationships with key health professionals to support people’s health and wellbeing such as the GP, psychiatrist, optician, dentist and chiropodist. Professionals’ views of the service obtained from a survey in May 2025 were positive about the service, “Always providing excellent care to residents and excellent communication.”

The provider was not always proactive in looking at opportunities for people to integrate within the wider community. We did not see any affiliation with any organisations within the community with the intention of improving people’s outcomes. People who could, accessed the community independently, and had people to see and places they liked to go.

The provider did not focus on continuous learning, innovation and improvements across the service. There was a lack of forethought in keeping up to date with current thinking, not utilising available resources or recognising improvements needed to the service and how to make them happen.

There was no consistent approach to measuring outcomes and impact on people’s care treatment and support and the development of the service as whole. There was little in place to enable innovation and improvement to the quality and safety of care to take place and there was no strategy to address this shortfall. There were no effective arrangements or plan in place to ensure the provider was providing a service in line with Right support, right care, right culture. This was evident in the concerns we found during the assessment.