CQC report explained · a residential care home
What the CQC found at Berrycroft Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2022
Berrycroft Manor was rated Requires Improvement; inspectors found unsafe medicines and gaps in risk records, although care was kind and responsive.
Inspectors visited without notice on 26, 27 and 28 July 2022. They spoke with 10 people, two relatives and 12 staff. They reviewed seven care records, nine medicines records and other service records.
The main safety concerns were medicines not always being given or recorded safely, and care plans and monitoring records not always reflecting people's current risks. One person was given more medicine than prescribed on five occasions. Inspectors also found the home's checks had not identified these problems.
The home was rated Good for Responsive care. People said staff knew them well, were kind and responded to their needs. However, the overall rating fell from Good at the previous inspection, published in January 2019, to Requires Improvement.
Kind, personalised care
People said staff knew their routines, likes and dislikes. Care files were person-centred and reflected people's preferences.
“Care files were person centred and reflected people's preferences for their care and support.” from the report
Responsive management
Managers were described as supportive and approachable. They responded quickly when inspectors raised concerns and supplied evidence of changes after the visit.
“The management team were helpful and quick to investigate when we fed back our findings during the inspection.” from the report
Staffing and recruitment checks
Inspectors found enough suitable staff to meet care needs and saw checks such as DBS checks and references for recruitment.
“Sufficient numbers of suitable staff were employed to meet people's care needs.” from the report
Complaints were handled
People were told how to complain, and inspectors found that complaints had been responded to appropriately.
“We reviewed the home's complaints and saw that complaints were responded to appropriately.” from the report
Positive experiences reported
People and relatives told inspectors they felt safe and cared for, and staff were described as friendly and kind.
“Everyone we spoke with was happy and felt cared for at the home.” from the report
Medicines safety
seriousMedicines were not always recorded or given safely. This included missing administration records, unclear guidance for medicines given when needed, and one person receiving a higher dose than prescribed on five occasions.
“One person had been given a higher dose than what the doctor had prescribed on five occasions in June and July 2022.” from the report
Incomplete risk information
seriousSome care plans and risk assessments were out of date after people returned from hospital. Monitoring records, including repositioning charts, were also incomplete or inaccurate.
“People had been placed at the risk of harm from inaccurate or incomplete risk management plans.” from the report
Weak management checks
seriousThe home's audits did not always identify or act on the problems found by inspectors. This meant there was not enough oversight of medicines and care records.
“A suite of audits was regularly carried out; however, they had not identified and actioned immediately the concerns found during this inspection.” from the report
Activities for people in rooms
needs fixingActivity staff were sometimes used to cover care shifts. There was no programme for individual activities or for people cared for in bed or choosing to stay in their rooms.
“We found there was no programme in place for individualised activities or for those people cared for in bed or those people who chose to stay in their room.” from the report
Infection-control details
minorSome staff did not wear masks correctly, hand sanitiser was not always available, and sluice rooms were not always locked. Managers said they would address these issues immediately.
“We were somewhat assured that the provider was using PPE effectively and safely.” from the report
- 01What checks now make sure every medicine is given at the prescribed dose and recorded, including when the internet system is unavailable?
- 02How are care plans updated after someone returns from hospital, especially for eating, drinking and repositioning needs?
- 03How do managers check that repositioning and other care records are complete and accurate every day?
- 04How will activity staff avoid being moved to care duties, and what individual activities are offered to people who stay in their rooms?
- 05What evidence can you show that the improvements promised after the inspection have been completed and are working?
This was an unannounced inspection prompted partly by concerns about medicines, unmet needs, staff behaviour and staffing; Safe, Responsive and Well-led were reported, while other ratings were not given in this report and may have carried over from the previous inspection. This explanation was written from the published report of 16 September 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.
What inspectors found, January 2019
Berrycroft Manor was rated Good; inspectors found safe, kind and personalised care, with some records still being transferred to a new electronic system.
Inspectors visited the home without warning on 27 and 28 November 2018. They spoke with people living there, relatives, staff and managers. They reviewed care files, medicines records, staff files and management records.
The home was rated Good overall and Good in all five areas. Inspectors found people were safe, treated with kindness and involved in decisions about their care. Medicines, staffing, safeguarding, infection control and risk assessments were managed well.
The home supported people living with dementia and offered activities seven days a week. It had systems to monitor quality and respond to complaints. Some paper care information was still being moved to the electronic system, and records of staff meetings were not always complete.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and saw medicines being managed accurately by trained staff.
“Medicines administration records had been completed accurately and consistently.” from the report
Personalised care
Care files recorded people's preferences and how they wanted to be supported. People and relatives were involved in care planning and reviews.
“Care files contained personalised information about the people who lived at the home and how they wished to be supported and cared for.” from the report
Kind and respectful staff
People described staff positively, and inspectors observed patient interactions that supported dignity, choice and independence.
“Staff were observed to be kind, caring and patient in their interaction with people, taking time to engage in conversation and share a laugh and a joke with people” from the report
Quality monitoring
The manager used audits, feedback and action plans to check the service and make improvements.
“The registered manager completed a range of audits and quality monitoring, to ensure care provided was of a high quality and met people's needs.” from the report
Electronic care files still being completed
needs fixingThe home was moving information from paper files to an electronic system. Inspectors said some information had not yet been scanned or added, so families should check that their relative's current information is complete.
“The transition between paper based files and the electronic ones was still an ongoing process, with some information still to be scanned and/or added to the new system.” from the report
Staff meeting records
minorStaff meetings were taking place, but there was no clear schedule and not all minutes had been typed up. The manager said this would be addressed.
“There was no clear schedule as to when meetings had been held, however from speaking to staff it was apparent meetings had occurred more frequently than meeting minutes suggested.” from the report
- 01Has all information from paper care files now been transferred to the electronic system, and how do you check that nothing important is missing?
- 02How do you decide how many staff are needed for each shift, and how often are dependency levels reviewed?
- 03How are staff meeting dates, discussions and actions recorded now?
- 04How are activities matched to the interests and abilities of each person, including people living with dementia?
- 05How will my relative and our family be involved in creating and reviewing the care plan?
This was an unannounced inspection of the care home, covering all five CQC questions and both the premises and care provided. This explanation was written from the published report of 12 January 2019 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 Berrycroft Manor
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 24 December 2010.
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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