CQC report explained · a nursing home
What the CQC found at Bryher Court Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some health and safety risks were not clearly assessed or recorded, including choking, diabetes management and catheter care. There were enough staff, medicines were managed safely, and infection control arrangements were in place.
- Effective?
- Requires improvement
- The home did not always follow the Mental Capacity Act when assessing capacity, recording consent and making best-interest decisions. Training and supervision had started to improve, and people were supported with food, drink and healthcare.
- Caring?
- Good
- This question was not inspected during this focused inspection. Inspectors observed open and friendly relationships, and people said they were happy.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Inspectors noted that some care was not always person-centred, including missing activity information and some preferences not being followed in records.
- Well-led?
- Requires improvement
- The manager and provider had started improvements, but audits had not identified all the problems with care plans, recruitment records and mental capacity assessments. The new manager was approachable and staff described a positive culture.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found risks, consent records and quality checks that needed urgent improvement.
This was an unannounced focused inspection on 28 February and 6 March 2023. Inspectors reviewed records, medicines, care plans, risk assessments and recruitment files. They spoke with people, visitors, staff and health and social care professionals, and observed care and mealtimes.
The home was clean, had enough staff and people received their medicines, food and drink. Staff understood safeguarding procedures and people described friendly relationships with staff. However, some risks were not clearly assessed or recorded, including choking, diabetes and catheter care.
Inspectors found that mental capacity and consent processes did not always follow the law. Care plans and records were sometimes incomplete, inaccurate or conflicting. The home's audits had not found all these problems, although the manager and provider had started improvements.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe, Effective and Well-led. This is worse than the previous Good rating, published on 17 November 2017. Caring and Responsive were not inspected in this visit.
Clean and infection-aware
The home was clean and tidy, with arrangements to help prevent and manage infections.
“There was a cleaning schedule to guide staff.” from the report
Medicines support
Medicines were ordered, stored and given by trained and assessed staff. Records were completed after medicines were given.
“People were supported to receive their medicines when they needed them.” from the report
Enough staff
Inspectors saw people attended to promptly. Staff said there were enough staff on shifts, including when regular agency staff were used.
“There were enough staff working in the service to meet people's needs.” from the report
Good health and nutrition support
People were supported with meals, drinks, specialist diets and healthcare referrals when needed.
“People were supported to have enough to eat and drink throughout the day to meet their nutritional and health needs, individual choices and preferences.” from the report
Approachable management
People, visitors and staff described a positive culture. They said the manager was approachable and issues could be raised.
“People, visitors and staff spoke well of the manager.” from the report
Risk information was incomplete
seriousSome risks were not properly assessed or explained for staff. This included choking, diabetes and catheter care, creating a risk of unsafe care.
“People were at risk of harm because systems were not robust enough to demonstrate safety was effectively managed.” from the report
Consent and capacity processes
seriousMental capacity assessments were not always specific to the decision. Best-interest decisions and some consent records did not show how decisions had been made or who was involved.
“People did not have their care and support needs delivered in line with MCA.” from the report
Care records were not reliable
seriousSome care plans had missing, conflicting or inaccurate information. Audits had not identified all the problems.
“The provider did not have effective systems in place to monitor and improve the quality and safety of the service.” from the report
Recruitment records
needs fixingSome staff files did not contain a full employment history. Other checks, including references and DBS checks, had been completed.
“There was not always recorded a full employment history for some staff.” from the report
Person-centred information
needs fixingSome people's preferences and activities were not recorded clearly. Information about weights, personal care and other needs had also been displayed in communal corridors, but the provider said this had been removed after the inspection.
“There were no activity care plans to inform staff what people currently liked to do each day.” from the report
- 01What action has been taken to complete choking, diabetes and catheter risk assessments for every person who needs them?
- 02How are mental capacity assessments, consent records and best-interest decisions now being checked?
- 03How will you make sure care plans contain accurate, complete and consistent information for all staff, including agency nurses?
- 04What evidence can you show that the new training, supervision and electronic care planning system are working in everyday practice?
- 05How are people's activities, personal preferences and choices being recorded and followed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the overall rating used the previous ratings for any key questions not inspected. This explanation was written from the published report of 4 April 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 2021
Bryher Court Nursing Home was inspected but not rated; inspectors were assured about infection prevention and control during a coronavirus outbreak.
Inspectors visited the home on 3 February 2021. The visit was announced and focused on infection prevention and control during a coronavirus outbreak.
They found adequate supplies of protective equipment, staff using it correctly, regular testing, and hand sanitiser available throughout the home. They were also assured that visitors, new admissions, social distancing and outbreak management were being handled safely.
This was a targeted inspection. The home was not given an overall quality rating, and the Safe question was also marked inspected but not rated.
Protective equipment
Staff had enough protective equipment and were seen using it correctly. They also used visors as extra protection.
“Staff were provided with adequate supplies of personal protective equipment (PPE) and were seen to be wearing this appropriately.” from the report
Staff training and testing
Staff had specific coronavirus training, including how to put on and remove protective equipment safely. Testing was taking place for people living in the home and staff.
“Staff had received specific Covid-19 training and this included guidance for staff about how to put on and take off PPE safely.” from the report
Thoughtful room arrangements
When people stayed in their bedrooms, staff arranged beds so people could see outside their doors while keeping them further away from infection risks.
“Therefore, staff repositioned people's beds as far from the door as possible, but also positioned people so they could see outside of the door and still feel part of the home.” from the report
Inspectors raised no specific concerns in this report.
- 01How often are people and staff tested now?
- 02What arrangements are currently used to prevent visitors from bringing infections into the home?
- 03How are new admissions assessed and managed safely?
- 04What protective equipment and infection prevention training do staff receive now?
- 05How would the home manage another infection outbreak?
This was an announced, targeted inspection of infection prevention and control only; the home was inspected but not rated. This explanation was written from the published report of 20 February 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 Bryher Court Nursing Home
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- August 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2016Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 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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Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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