Berrycroft Manor

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

Risks to people were not always effectively managed and we found improvements were required to safeguarding processes, including the MCA. People received their medication safely, although PRN (when required) protocols were not always in place and some information regarding people’s medicines needed to be easier to locate. Some topical creams and drink thickeners were not always stored securely, although we found action was taken to address this concern. The home was clean, tidy and appropriate maintenance checks were carried out. People had access to support from other healthcare professionals when they needed and appropriate actions were taken following any accidents or incidents which occurred.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People living at the home and their relatives said appropriate actions were taken when incidents occurred. For example, after a fall. People said complaints were responded to appropriately.

The management team regularly analysed accidents and incidents to identify any emerging themes or patterns in order to improve the care provided. These findings were then shared with the staff team. Staff confirmed they were informed of any actions following an accident or incident through the daily meetings that took place. We observed daily ‘Huddle meetings’ taking place during the inspection, where any updates or progress could be shared with staff.

Where people had an accident or incident, this was recorded, monitored and action taken to address concerns. For example, where a person had an increase in falls this was identified and analysed to determine the potential cause of this. Where people required input from external professionals, appropriate referrals had been made, such as involvement from speech and language therapy and GP’s.

We didn’t receive any feedback from people living at the home in this area.

The service worked in partnership with other professionals such as GP's and dietitians to support people to access healthcare when they needed it. This had improved people's outcomes. The management team and staff demonstrated how when a person's needs had changed, they had promptly engaged with several services to ensure the person's needs were fully met and understood.

We didn’t receive any feedback from partners in this area.

We reviewed the provider's admission process and found key information was sought from the person, their relatives and any external professional involved in the person’s care to enable a positive transition into the service. We also found the assessment continued following their admission to ensure the staff had accurate and up to date information on people's needs and preferences.

People living at the home and relatives told us they felt the service was safe. One person said, “I feel well looked after, not restricted and safe, I feel safe as there are people around me day and night.”

Staff understood about safeguarding and how to protect people from harm. One member of staff said, “Risks to a person’s skin could be a safeguarding concern or if a member of staff was tormenting a resident. I would report this.”

During the assessment we observed staff treating people well, seeking their consent and in a respectful way. For example, we observed a member of staff assisting a person with their mobility from the dining room into a comfy chair.

There was a safeguarding policy and procedure in place which was in date and provided an overview about what people could do if they experienced any abuse. A safeguarding log was maintained, with details about any incidents reported to the local authority for further review. We looked at the systems in place to ensure DoLS (Deprivation of Liberty Safeguards) and MCA (Mental Capacity Act) processes were followed. People had consent care plans in place, which provided an overview of whether they had capacity to make certain decisions. MCA assessments were also completed where people were unable to advocate for themselves and covered areas such as covert medication and living at Berrycroft Manor. Some MCA assessments had not been completed, however. These included decisions such as the use of sensor mats in their bedroom and where people had been asking to leave the home, although were prevented from doing so by staff. We provided this feedback to the registered manager and these were put in place during the inspection.

People living at the home and their relatives told us they were involved in managing risks. One relative said, “The care plan is reviewed regularly and has been updated since (person) fell. The call bell has been moved to near the bed and the manager suggested a pendant that can be worn and two sensor mats are on place either side of the bed”.

Staff understood about people’s care needs and the risks presented to them. For example, people who may be at risk of choking, or skin breakdown.

We saw staff responding to people’s needs in a safe way during the assessment.

At our last inspection of the service in July 2022, we identified a breach of regulation 12 regarding safe care and treatment. This was because people’s monitoring charts were not always complete, or accurate. At this inspection, we found similar concerns, particularly with regards to the re-positioning of people during the night and how this was documented. We saw a letter was sent to all night staff, informing them of the potential implications of not maintaining accurate records. We also identified several other risks within the home which were not always effectively managed. This included people not always being sat on pressure relieving equipment as required and risk assessments not in place for people at risks of burns or scalds when making themselves a hot drink. Whilst some issues still remained, we received assurances from the registered manager that these areas would be addressed immediately. People’s preferred dietary needs were not always met. For example, people who were vegetarian were given meat options which they had stated they didn’t like, which were then documented on food intake charts. We provided this feedback to the registered manager, although they informed us the care plan for this person was inaccurate. We recommend all care plans are updated to ensure they reflect people’s current needs.

People living at the home and their relatives said the felt the home environment was safe. One relative said, “My loved one is in a safe environment; the building is secure, and you must be let in and out, and to enter the unit you must know the keycode.”

Staff spoken with during the inspection told us they felt the home environment was safe, secure and well-maintained.

We walked around the building and to ensure if was well maintained and safe for people to live in. We didn’t identify any concerns following these observations.

The building was safe and we viewed certificates of maintenance work completed around the home.

People living at the home and relative said there were enough staff to care for them safely. One person said, “If I press the buzzer the staff come very quickly, I think they must run to get here they so quick.” A relative told us, “The staff are plentiful and are helpful and easy to talk to.”

Overall, the feedback we received was that enough staff were available and that people’s care needs were met. Some night staff commented that plans were in place to have an extra member of staff available and this was currently being explored by the management team.

We observed there to be sufficient numbers of staff available during the assessment. We saw people being assisted by staff in a timely way.

Staffing rotas were in place and this demonstrated how many staff were required to care for people. Staff were recruited safely with the necessary pre-employment checks carried out. Staff received regular training, supervision and appraisal to support them in their role.

People living at the home told us felt the home was clean. One person said, “The home is well run; very clean the staff are lovely I have no complaints I would give it 10/10 and I would recommend it to anyone.”

Staff spoken with during the inspection told us they felt the home environment was clean and tidy.

We found the home to be clean and tidy and observed domestic staff carrying out their duties during the assessment.

Appropriate systems were in place to ensure safe infection control standards were maintained.

During the inspection we looked at stock levels of resident’s medicines. Overall, we found these to be correct and it was documented on the electronic system when medicines had been brought forward from a previous cycle. This ensured the home was not over-ordering excess stock that wasn’t needed. We found residents had their medicines available with no missed doses witnessed on their records. People that were living with Parkinsons’ Disease were given their medicines on time, which is important for their condition. Patches had been applied to different areas of the body to ensure maximum efficacy. The previous site of application was recorded on the electronic system, so that staff could then rotate the location site of the next dose to a different area. We did find that some medicines prescribed ‘as and when required’ (PRN) did not always have a PRN protocol in place, to ensure staff knew what doses to give and when. Several people’s PRN protocols did not match current dosage instructions as prescribed by the residents GP, and were lacking in-depth information to allow the safe use of these medicines. The manager acknowledged that these need to be improved throughout the home.

Staff informed us they had a good working relationship with the pharmacy that supplies the home’s medicines. They knew what processes to follow if they needed an ‘ad-hoc’ medicine outside of the usual monthly cycle. We saw evidence of in-depth monthly medicines audits being completed. Issues were highlighted in these audits which were completed by the home manager and deputies. These mainly revolved around poor documentation when PRN medicines had been given, or refusals not always explained. The audit showed that the medicines rooms were not always being locked. Weekly controlled drugs stock checks were completed on separate audit sheets by the deputy managers. When asked, numerous staff mentioned that they didn’t have time to complete their mandatory training and often did it in their own time at home. They also mentioned this was down to not having enough staff on certain shift patterns.

Temperatures were documented in medicines rooms and fridges to ensure medicines were being kept in the correct environment. Extra stock of medicines, creams and thickeners were kept separate from current stocks in a locked cupboard. In-use medicines were kept in drug trolleys organised by residents’ room number and photograph. Some people received their medicines ‘covertly’, hidden in food or drink, due to their health needs and capacity. We did witness letters from GPs authorising the use of covert administration. However, there was no in-depth documentation from a pharmacist to ensure these were being given appropriately and safely. Care plans around people’s specific needs, eg: epilepsy, Parkinsons’ Disease and diabetes were not easy to locate on the online care notes. The home acknowledged these could be more easily accessible, to ensure staff know where to look for more information around people’s care needs. On the first day of the assessment we observed some topical creams and a drink thickener were not stored securely. We asked for these to moved somewhere people would not have access to them. This had improved by the second day of the assessment.