CQC report explained · a nursing home
What the CQC found at Berwick Grange
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing, risk assessment and safety management were not always sufficient. Medicines and infection prevention were generally managed safely, but inspectors found breaches relating to staffing and safe care and treatment.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Governance and provider oversight were not reliable or effective. The home had begun making improvements, but the systems for identifying and dealing with risks were not yet working consistently.
What inspectors found, February 2023
Requires Improvement; inspectors found risks from staffing, care planning and weak management checks.
This was an unannounced focused inspection on 25 November and 6 December 2022. Inspectors reviewed six care records, five medicines records, staff records, audits and other documents. They spoke with people, relatives and staff.
The home was not always safe. It relied heavily on agency staff, and staff were not always deployed well enough. Risk assessments and guidance were incomplete. Some safety issues, including restricted access to fire extinguishers and missed fire evacuation practice, had not been dealt with promptly.
Management checks were not reliable. Safeguarding concerns, accidents and incidents were not always reviewed or acted on quickly. The home had started an improvement plan, and staff and managers were working with the local authority to make changes.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were rated Requires Improvement. This was a focused inspection, so the other three question ratings were not assessed and the previous ratings were used when calculating the overall rating.
Medicines
Inspectors found that medicines were received, stored and given safely, in line with people's preferences. Records and checks were described as clear and well organised.
“Medicines were received, stored and administered safely and in line with people's preferences.” from the report
Staff knowledge
Staff who knew people well understood their needs. Permanent staff were described as caring and knowledgeable, although this was affected by the use of agency workers.
“Staff understood their role and knew the people they cared for well and how to meet their needs.” from the report
Improvement work
The manager and staff were working on an action plan. Staff had confidence in the direction of the service and were keen to improve it.
“There was a sense of a shared passion amongst the staff team to improve the service and the experience for the people they cared for.” from the report
Family involvement
Relatives said they were kept informed about their relatives' care. Meetings, questionnaires and staff supervision had been reintroduced.
“Relatives told us they were kept up to date with on their loved ones care.” from the report
Agency staffing
seriousThe home relied heavily on agency support workers. Staff were not always deployed effectively, and some agency workers did not know people well enough to provide person-centred support.
“Staff were not always effectively deployed on one of the units meaning staff were not always available to redirect and support people when needed” from the report
Incomplete risk management
seriousSome risks were not fully assessed and staff did not always have clear guidance. Inspectors also found fire safety issues that had not been addressed promptly.
“The provider had failed to assess and mitigate the health and safety risk to people.” from the report
Weak management checks
seriousAudits and oversight did not reliably identify or deal with problems. Accidents, incidents and safeguarding concerns were not always reviewed or acted on quickly.
“Governance and performance management was not always reliable and effective.” from the report
Mental Capacity Act practice
needs fixingThe home was not always working within the Mental Capacity Act principles. Capacity records could conflict, and door sensors and photograph consent forms were sometimes used in a standardised way.
“We found the service was not always working within the principles of the MCA.” from the report
Infection control equipment
minorInspectors were only somewhat assured that personal protective equipment was being used effectively and safely. They signposted the provider to resources for improvement.
“We were somewhat assured that the provider was using PPE effectively and safely.” from the report
- 01How many permanent and agency staff are usually on each unit, and how do you make sure agency staff know each person's needs?
- 02What has changed since the inspection to make sure risk assessments and staff guidance are complete and up to date?
- 03Have regular fire evacuation practices been completed, and is access to all fire extinguishers now clear?
- 04How are safeguarding concerns, accidents and incidents now reviewed, recorded and followed up?
- 05How do you make sure door sensors and other restrictions are agreed in each person's best interests and are the least restrictive option?
This was a focused inspection of Safe and Well-led only; the other three question ratings were not inspected and the previous ratings carried over when calculating the overall rating. This explanation was written from the published report of 2 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, March 2021
Berwick Grange was inspected but not rated; inspectors found infection-control arrangements that gave them assurance.
This was an announced, targeted inspection on 3 February 2021. It checked infection prevention and control measures during the COVID-19 pandemic.
Inspectors were assured that the home used PPE safely, screened visitors, followed social distancing rules and tested staff and residents. They also found daily enhanced cleaning, a clean environment and plans for managing outbreaks.
The home supported contact with relatives through screened visits, garden visits and video calls. The inspection was not rated, so it does not provide an overall rating of the home's care.
Visitor safety
Visitors were screened and had their temperatures checked. Essential visitors were supervised so that distancing and infection-control rules were followed.
“Screening questions and a temperature check were standard requirements for all visitors.” from the report
Contact with relatives
Residents could keep in touch with relatives through screened visits, garden visits and video calls.
“People were supported to maintain contact with their relatives in different ways including screened visits and video calls.” from the report
PPE and training
Staff had training in safe infection-control practices, used suitable PPE and had plentiful supplies available around the home.
“All staff were trained in safe IPC practices.” from the report
Cleaning and outbreak planning
Inspectors found the environment clean and hygienic. The home had plans for preventing or managing an infection outbreak.
“Enhanced cleaning took place daily. The environment was clean and hygienic.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors screened now, and how are essential visits supervised?
- 02How often are staff and residents tested for COVID-19 or other infections now?
- 03How are PPE supplies checked and how is staff infection-control training kept up to date?
- 04What arrangements are currently available for residents to see or speak with relatives?
- 05What is the current plan if there is an infection outbreak in the home?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it was not rated and did not assess the home's wider care. This explanation was written from the published report of 5 March 2021 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 Berwick Grange
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- June 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,010 to £1,290 a week. 27 can care for a couple. 12 years' experience on average.
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