CQC report explained · a residential care home
What the CQC found at 17 Berryfield Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and reviewed, with clear instructions for staff. Medicines were securely stored, records were complete and staff had appropriate training.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- Care plans were personal, clear and up to date. People were supported with communication, chosen activities, relationships and decisions about end of life care.
- Well-led?
- Good
- The provider had effective checks on care records, medicines, care plans and staff files. The previous breach about keeping care records accurate and clear had been resolved.
What inspectors found, October 2019
Rated Good; inspectors found safe, person-centred care and clear improvements since the previous inspection.
This was an unannounced focused inspection on 11 September 2019. One inspector met two people, observed staff, reviewed three people's care records and checked management records. The inspector also spoke with the registered manager and two support staff.
The home supported four people with learning disabilities. Inspectors found that people were safe, their medicines were managed properly and staff understood their needs. People were supported to make choices, build independence, communicate in ways that suited them and take part in activities they chose.
The home had improved since the previous inspection. Risk assessments and care plans were clearer and more up to date. The earlier breach about good governance had been resolved, and the overall rating changed from Requires Improvement to Good.
The inspection only assessed Safe, Responsive and Well-led. The overall Good rating also used ratings from the previous comprehensive inspection for the areas not looked at this time.
Clear risk planning
Risk assessments balanced people's safety with their independence and choices. Staff understood the actions they needed to take.
“The plans contained clear information about the support staff needed to provide to support people to manage the risks they faced.” from the report
Safe medicines support
Medicines were locked away, records were complete and staff were trained and checked. Daily checks and monthly audits helped identify problems early.
“Medicine administration records had been fully completed, which gave details of the medicines people had been supported to take.” from the report
Personalised communication
The home recorded people's communication needs and used methods such as signs, gestures, symbols and pictures.
“Methods to support people included using objects of reference, signs and gestures, and written documents made more accessible through the use of symbols and pictures.” from the report
Choice and activities
People were supported to choose activities, attend a local day service, plan holidays and take part in special events.
“People were supported to take part in a range of activities they had chosen.” from the report
Improved governance
The provider had improved care planning and risk records after the previous inspection. Quality checks were being used to monitor the home.
“The provider had effective quality assurance systems in place.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now check that care plans and risk assessments remain accurate and up to date?
- 02How are people involved in reviewing their care plans and making decisions about risks?
- 03What training and checks do staff currently receive for medicines, including rescue medicines?
- 04How do you make sure people can choose activities and communicate their preferences?
- 05What were the previous ratings for Effective and Caring, and how are these areas monitored now?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not assessed and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 19 October 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.
What inspectors found, July 2019
Ordinary Life Project Association - 17 Berryfield Road was rated Requires Improvement; inspectors found kind care and safely managed medicines, but care records and risk guidance were not reliable.
This was an unannounced inspection on 14 May 2019. One inspector reviewed information held by CQC, spoke with one person and two staff, and checked care records, staff records and management records.
The home was rated Good for Effective and Caring. People said they felt safe, staff were kind, medicines were managed safely, dietary and healthcare needs were met, and staff had training and support.
The home was rated Requires Improvement for Safe, Responsive and Well-led. Care plans and risk assessments were often unclear, duplicated or out of date. Information about people's preferences and communication was not always used in their care plans. The home had enough staff, but vacancies were covered with regular agency staff.
The overall rating fell from Good at the previous inspection in July 2016 to Requires Improvement. CQC found a breach of Regulation 17 because records were not complete, clear, accurate and up to date. The provider was asked to send an action plan, which CQC said it would check.
Medicines managed safely
Medicine records included photographs and administration records were signed. There were also arrangements for disposing of medicines no longer needed.
“Medicine files held essential information with person's photographs to ensure staff were able to recognise the person.” from the report
Good healthcare support
People had health action plans, annual health checks and guidance for specific health needs. Hospital passports recorded important information for hospital admissions.
“People had annual health checks with their GP.” from the report
Staff training and support
New staff received an induction and staff completed mandatory training. Staff also had opportunities for one-to-one meetings and further qualifications.
“The staff were supported to meet the responsibilities of their roles and to develop their skills.” from the report
Inaccurate and unclear records
seriousCare plans and other records were duplicated, amended in confusing ways and not always consistent. This was the reason for the Regulation 17 breach.
“The above concerns demonstrated a failure to ensure records were complete, legible, accurate and up to date.” from the report
Unclear risk guidance
seriousSome risk assessments contained old or crossed-out information, so it was not always clear what equipment or actions staff should use to reduce risks.
“Some risk assessments were difficult to follow because of the number of amendments.” from the report
Care plans not person centred
needs fixingCare plans focused on the help staff needed to provide for tasks rather than consistently describing the person's preferences, goals and choices.
“Care plans were not person centred and were based on the assistance needed from staff for tasks.” from the report
Capacity reviews not fully recorded
needs fixingSome mental capacity assessments were not reviewed when circumstances or legislation had changed. Date changes did not provide enough evidence that a proper review had taken place.
“People's mental capacity was assessed, but the assessments were not always reviewed when there were changes to the person's mental capacity.” from the report
Overgrown garden
minorThe rear garden was overgrown and could be difficult for a person with pets to access.
“The garden to the rear was overgrown and would be difficult for the person with pets to access.” from the report
- 01Which care plans and risk assessments have been rewritten since the inspection, and how do you check that they are accurate and consistent?
- 02How do you make sure staff can quickly find the current guidance about each person's risks, preferences, communication and behaviour?
- 03How are mental capacity assessments reviewed when a person's circumstances or the surrounding rules change?
- 04How many permanent staff vacancies remain, how often are agency staff used, and how do you ensure agency staff know people's needs?
- 05What action has been taken to improve access to the rear garden?
This was an unannounced scheduled inspection that looked at the premises, care and management of the home, including all five CQC questions; the previous inspection had rated the service Good in July 2016. This explanation was written from the published report of 12 July 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 17 Berryfield Road
3 rated inspections over 3 years: the service has held its Good rating throughout.
- October 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 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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