Background to this inspection
Updated
25 January 2022
The inspection
This was a targeted inspection to check whether the provider had met the requirements of the specific concern we had about staffing levels, use of restraints, unsafe medicine administration and lack of management oversight.
Inspection team
This inspection was undertaken by two inspectors and one inspection manager.
Service and service type
Berkeley House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with one permanent support worker, five agency support workers and three supporting managers from another service. We carried out various observations throughout the inspection visit.
We reviewed a range of records. This included four people’s care records daily records and medication records. A variety of records relating to the management of the service, including rosters were reviewed.
After the inspection
We looked at training data sent to us.
Updated
25 January 2022
About the service
Berkeley House is a residential care home providing personal care to 16 people who have learning disabilities or autistic spectrum disorder. The service can support up to 19 people within the four separate houses, The Windmill, The Granary, The Bakery and Pippin.
People’s experience of using this service and what we found
During the inspection, the majority of risks and concerns were identified in the Bakery House. However, other concerns were also found in the Windmill house.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.
Right support:
• Model of care and setting did not maximise people’s choice, control and independence
People were not always supported to be as independent as possible. A staff member was observed forcing a person into their wheelchair against their wishes. The setting did not maximise people’s choice and control, one of the buildings was being decommissioned and therefore people had been given notice to leave.
Right care:
• Care was not person-centred and did not promotes people’s dignity, privacy and human
Rights
People had not been consistently supported in a person centred and positive way. People’s dignity and privacy had not been upheld. One person had no blinds or curtains at their window, their window was also permanently fixed open. People’s basic human rights were not upheld as they were unable to access toilet paper, in the Bakery house, on the morning of our inspection.
Right culture:
• Ethos, values, attitudes and behaviours of leaders and care staff did not ensure people
using services lead confident, inclusive and empowered lives
The culture within the service was poor. Some staff spoke to people in a degrading manner. People were referred to a ‘verbal’ and ‘non-verbal’. There was a lack of respect from staff and management regarding the environmental aspects of the service. Staff told us that other staff members had been careless with people's bedroom furniture, and this had caused damage and the furniture had not been replaced. People’s bedrooms were dirty and unhygienic.
People living in the Bakery were living in unclean and unsafe conditions. They were not protected from the risk of harm or abuse. Safeguarding incidents had not been consistently recorded or reported to the local authority safeguarding team so they could be investigated.
Risks to people’s health were not always identified. No guidance had been provided to staff about how to support people with other risks. Risks relating to the environment had not been mitigated to keep people safe.
The service was not clean. Peoples bedrooms were dirty and unhygienic and posed a risk to their health. Government guidance regarding wearing and disposing of personal protection equipment was not being followed.
There were not enough suitably qualified and experienced staff to support people with their individual care needs.
There had been no review of incidents and accidents and they continued to happen. No trend analysis had been completed and actions had not been to be taken to mitigate future reoccurrence of incidents.
There was a poor culture within the service. Staff were heard speaking to people in a degrading manner. There was a lack of respect for people’s dignity and personal belongings.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
There was a lack of oversight from senior management regarding quality assurance within the service.
Following this inspection, we worked closely with the local authorities to make sure people were safeguarded from ongoing harm. Seven people were supported to move out of the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 16 June 2021)
Why we inspected
The inspection was prompted in part due to concerns received by another healthcare professional. The concerns raised were in areas such as poor leadership, poor risk management, people not being kept safe from abuse or harm and people living in poor and unsanitary conditions. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Berkeley House on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to the service not being able to keep people safe from harm or abuse, inadequate risk assessments and guidance for staff surrounding risks to people, insufficient suitably qualified staff, failure to treat people with dignity and respect, failure to follow legal framework for consent to care being provided and failure to effectively monitor the quality of the service at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
Following the inspection, we took urgent action to restrict admissions to the service. This meant that people living in The Bakery moved out of the service immediately following our inspection as they were not safe living there. We also took urgent action and required the provider to ensure staff were trained in administering medication to people living with epilepsy. The provider has cancelled their registration of Berkeley House. Everyone has now moved out of the service and Berkeley House is now closed.