CQC report explained · a nursing home
What the CQC found at Berkeley Park
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks were assessed, medicines were generally managed safely, and infection prevention arrangements were in place, although some environmental and medicine-record issues were found and addressed.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Good
- Managers had oversight of the home, acted quickly when issues were identified and used audits and other systems to monitor care. Staff said managers were approachable.
What inspectors found, February 2023
Alexandra Court was rated Good; inspectors found safe, kind care, but some environmental and record-keeping issues needed action.
This was an unannounced focused inspection on 12 and 20 January 2023. Inspectors looked at Safe and Well-led because concerns had been raised about staff attitudes, call bells and hydration. They spoke with people, relatives and staff, and reviewed care, medicine, staff and management records.
The home was rated Good for Safe and Well-led. Inspectors found that people were safeguarded, risks were assessed, medicines were generally managed safely, and there were enough trained staff. People and relatives said they felt safe, and people described staff as kind and caring.
Inspectors found some problems with the building, including shower rooms, clutter, unsecured wardrobes and appliances needing testing. Managers acted immediately, started improvement work and put an action plan in place. Some medicine records lacked two staff signatures, and some staff induction records were incomplete.
People felt safe
People and relatives told inspectors they felt safe. Call bells were available, and people said staff usually responded quickly.
“People told us they felt safe living at the home, and relatives confirmed this.” from the report
Safe medicines systems
The main processes for receiving, storing, giving and disposing of medicines were safe. Staff who gave medicines had been trained.
“Medicines were managed safely, and people received their medicines when they should.” from the report
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff involve people in discussions and respect their privacy and choices.
“People told us staff were caring and kind.” from the report
Active management
Managers responded promptly to problems found during the inspection. Audits and governance systems gave leaders oversight of the service.
“Governance systems ensured the registered manager and provider had oversight of the service.” from the report
Building condition
needs fixingSome shower rooms and other parts of the building needed improvement. Inspectors also found clutter, unsecured wardrobes and appliances needing re-testing, although action was started during the inspection.
“some areas of the building including shower rooms needed upgrading to ensure they did not present an infection control risk.” from the report
Medicine signatures
needs fixingSome topical cream and medicine administration records did not have the required two staff signatures. No harm had occurred, and the clinical lead acted during the inspection.
“Topical cream administration records and some medication administration records did not always have 2 staff signatures.” from the report
Incomplete induction records
minorSome staff did not have a formal record showing their induction had been completed. Managers said they would audit staff files.
“However, some staff did not have a formal record of induction.” from the report
- 01What work has been completed on the shower rooms and other environmental issues identified during the inspection?
- 02How do you now check that medicine records have two staff signatures where required?
- 03Has the audit of staff induction records been completed, and were any gaps found?
- 04How will you assess and review my relative's rehabilitation, hydration and call-bell needs?
- 05Which ratings were carried forward from the previous inspection, and when will those areas next be assessed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 22 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Alexandra Court was inspected but not rated; infection controls were in place, but visitor vaccine rules were not in line with government guidance.
This was a targeted inspection on 12 January 2022. It followed concerns about visiting rules during the COVID-19 pandemic. Inspectors looked mainly at infection prevention and control, and asked about staffing pressures.
Inspectors found that testing, protective equipment, cleaning, ventilation, social distancing and arrangements for people who needed to self-isolate were in place. They found enough staff to care for people safely, although recruiting full-time nurses had been difficult.
Visitors had been required to show proof of both vaccine doses before entering. Inspectors said this was not in line with government guidance at the time. They spoke with seven relatives, and found no reported impact on people's wellbeing from the visiting restriction.
The home was inspected but not rated. This means the inspection did not provide an overall quality rating or full ratings for all five areas of care.
Infection control
The home had measures to reduce the spread of COVID-19, including testing, PPE, isolation arrangements and infection control audits.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Staffing
Inspectors found enough staff to care for people safely. Additional infection control training had been provided during the pandemic.
“There were enough staff to care for people safely, with staff receiving additional infection control training during the pandemic.” from the report
Clean environment
The home was clean and tidy, with domestic staff carrying out cleaning duties during the inspection.
“We observed the home to be clean and tidy, with domestic staff carrying out their duties throughout the day.” from the report
Protective equipment
Inspectors saw staff using PPE throughout the visit, and enough PPE was available.
“Enough PPE was available and we saw staff wore it at all times during our visit.” from the report
Visiting rules
needs fixingVisitors had to show proof of both COVID-19 vaccine doses before entering. Inspectors said this did not follow government guidance at the time.
“At the time of our inspection, this was not in-line with government guidance, however, we found this had not impacted people's well-being as a result.” from the report
Nurse recruitment
minorThe home had found it difficult to recruit full-time registered nurses. Inspectors said this had not affected the care people received during the inspection.
“The home had experienced some workforce issues, such as recruiting full-time registered nurses, although this did not impact the care people received.” from the report
- 01What are the current visiting rules, and do visitors still need to show proof of vaccination?
- 02How many full-time registered nurses are currently employed, and are there still nurse recruitment pressures?
- 03What infection prevention measures are currently used if someone tests positive for COVID-19?
- 04How are relatives supported to keep in contact if visiting is restricted?
- 05When was the home last given a full inspection covering caring, effectiveness, responsiveness and leadership?
This was a targeted inspection of infection prevention and control, with questions about staffing pressures; it was not a full inspection of all five quality areas. This explanation was written from the published report of 24 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Berkeley Park
7 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- August 2021GoodSafe: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not rated
- January 2021GoodSafe: GoodWell-led: Requires improvement
- October 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- June 2019Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
- May 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2015
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 26 July 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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