Berrycroft Manor

This inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk and staffing levels. This inspection examined those risks.

We found some improvements in the management of medicines since the last inspection, for example, the supporting documentation for ‘when required’ medicines should be given and staff received training and competency checks. However, we found concerns relating to the accurate recording of some medicines and the safe spacing of medicine administration. There was a breach of regulation in relation to medicines.

We found staff were kind and caring during our observations of care delivery. However, we found there was not enough care staff on duty to always respond to people’s needs in a timely way, and we found not all staff had completed training as required. We had specific concerns around night-time staffing levels. There was a breach of regulation in relation to safe staffing.

We found the home to be mostly clean, well maintained and safety checks were in place. However, on our first site visit, we found people could access some areas that may not be safe; this was rectified by the registered manager after we had reported our concerns.

People received medical attention when required and staff made appropriate referrals to healthcare professionals when needed. People had individual care plans and risk assessments in place that were person-centred; however, we found these were not always up to date or reflective of people’s immediate needs and did not always provide clear direction to meet people’s needs safely. Where people required additional monitoring actions, we found records did not always demonstrate that people were receiving care in line with their assessed needs. There was a breach of regulation in relation to individual risk management.

The management team were helpful and quick to take necessary action when we fed back our concerns during the site visits. However, systems and processes to ensure oversight of the service were not always effective. Audits completed had not always identified the concerns we found on inspection. We received mixed feedback from people and staff about the management of the service, and we were not always assured that actions had been taken when concerns had been raised. There was a breach of regulation in relation to governance and oversight of the service.

We have asked the provider for an action plan in response to the breaches found at this inspection.