Archived: Berkeley Court

Updated 29 April 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014. As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by three inspectors including a medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Berkeley Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Notice of inspection

We gave the service 24 hours’ notice of the first day of our inspection. This was because we wanted to make arrangements to visit safely during the COVID-19 pandemic.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

On 9th March 2021 two inspectors visited the care home to observe care, speak with staff and check records. On 11 March 2021 an Expert by Experience made video and phone calls to people who used the service and their relatives. On 17 March 2021, a medicines inspector visited the home to examine the medicines management system. Between 9 March 2021 and 29 March 2021, we reviewed care and management records remotely. In total, we spoke with four people who used the service and eight relatives about their experience of the care provided. We spoke with ten members of staff including the district manager, regional support manager, registered manager, senior care workers, care workers and the catering manager.

We reviewed a range of records. This included elements of six people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two professionals who regularly visit the service.

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 www.cqc.org.uk

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.

Enforcement

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 report incidents to CQC and good governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the quality of standards and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.