We carried out a review of the data available to us about Belvoir Care Home Limited on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Belvoir Care Home Limited, you can give feedback on this service.
Belvoir Care Home Limited is a care home providing personal care to older people and people living with dementia. The service accommodates 24 people in one adapted building, over 2 floors. The service has 19 bedrooms, of which 5 are double rooms for families. At the time of the inspection 19 people were using the service and no bedrooms were being used for double occupancy.
People’s experience of using this service and what we found
The building was designed to meet the needs of the people receiving care. However, observations and feedback received highlighted the need for some renovations and upgrades. We made recommendations about further enhancing dementia-friendly environments.
Staff were trained to recognise potential risks and signs of abuse. Risks to people's safety and wellbeing were assessed and reviewed by the registered manager. Staffing levels were safe. The provider managed medicines safely. Staff used personal protective equipment (PPE) appropriately when supporting people.
People's needs were assessed and reviewed regularly. Healthy lifestyles were promoted, and systems were in place to make sure people's health needs were met. Menu planning met people's dietary needs and considered individual and cultural preferences. Staff had the skills and knowledge to deliver care effectively.
Staff knew how to communicate effectively with residents and were trained to meet people's needs at the end of their lives. Activities were meaningful and supported social inclusion. Relatives were encouraged to visit and had access to care plans where appropriate.
People told us staff were polite and always asked before providing care and support. Care plans were personalised and showed the care and support people wanted and needed. People and relatives knew how to raise concerns and were confident these would be dealt with appropriately.
The provider ensured systems were in place to monitor the running of the service. Staff worked well in partnership with other agencies to deliver effective care. The registered manager audited care and support records, to assure themselves of quality. Lessons were learned when concerns were raised, and these outcomes were communicated to staff.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
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 good (published 19 October 2017).
Why we inspected
We undertook this inspection as part of a random selection of services rated good, and due to the length of time since the service was last inspected.
Recommendations
We have made a recommendation about the design and decoration of the service.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Belvoir care home is a residential care home providing nursing and personal care for up to 24 people. Accommodation was provided in one single adapted building. We found the following examples of good practice.
¿ Temperature checks were undertaken prior to entry. There was a booking system in place for window visits and measures were in place to commence face to face visiting.
¿ The home was clean and hygienic. There was good ventilation within the home and the provider had also invested in an air purifying system.
¿ National guidance was followed on the use of personal protective equipment and the service had sufficient stock. There was prominent signage throughout the home reminding people to wash their hands.
¿ There were good lines of communication in place, with families being updated by phone, email and videocalls. Relatives had been consulted about their preferences regarding visiting.
¿ Staff and residents were taking part in regular covid 19 testing and the vaccination programme. Risk assessments had been carried out on people and staff belonging to higher risk groups and actions taken to reduce the risks.
Further information is in the detailed findings below.
The Belvoir Care Home is registered to provide personal care and accommodation for up to 24 older people. There were 18 people using the service at the time of the inspection.
The Belvoir Care Home is a detached property that has been converted and extended. It is situated on a main road in Wardle, close to public transport networks, local shops and facilities. There is ramped access to the front of the home and on-street car parking at the side of the home. There is a small garden to the side and rear of the building with a patio area to the front.
The home had a manager registered with the Care Quality Commission (CQC) who was present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found that suitable arrangements were in place to help safeguard people from abuse. Staff knew what to do if an allegation of abuse was made to them or if they suspected that abuse had occurred. Staff were able to demonstrate their understanding of the whistle blowing procedures (the reporting of unsafe and/or poor practice).
We found people were cared for by sufficient numbers of suitably skilled and experienced staff who were safely recruited. Staff received the essential training and support necessary to enable them to do their job effectively and care for people safely.
The medication system was safe and we saw how the staff worked in cooperation with other healthcare professionals to ensure that people received appropriate care and treatment.
Procedures were in place to prevent and control the spread of infection and risk assessments were in place for the safety of the premises. All areas of the home were secure, clean, well maintained and accessible for people with limited mobility; making it a safe environment for people to live and work in.
Systems were in place for carrying out regular health and safety checks and equipment was serviced and maintained in accordance with the manufacturers’ instructions.
Procedures were in place to deal with any emergency that could affect the provision of care, such as a failure of the electricity and water supply.
People told us they received the care they needed when they needed it. They told us they considered staff were kind, had a caring attitude and felt they had the right skills and knowledge to care for them safely and properly. We saw that staff treated people with dignity, respect and patience.
We saw people looked well cared for and there was enough equipment available to ensure people's safety, comfort and independence were protected.
People's care records contained enough information to guide staff on the care and support required. The records showed that risks to people's health and well-being had been identified and plans were in place to help reduce or eliminate the risk. We saw that people were involved and consulted about the development of their care plans.
Specialised training was provided to help ensure that staff were able to care for people who were very ill and needed ‘end of life’ care.
Staff were also able to demonstrate their understanding of the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.
People were provided with a choice of suitable and nutritious food and drink to ensure their health care needs were met.
To help ensure that people received safe and effective care, systems were in place to monitor the quality of the service provided. Regular checks were undertaken on all aspects of the running of the home and there were opportunities, such as resident/relative meetings and satisfaction surveys for people to comment on the facilities of the service and the quality of the care provided.
Records we looked at showed there was a system in place for recording complaints and any action taken to remedy the concerns raised. Records showed that any accidents and incidents that occurred were recorded.
Belvoir Care home provides personal care and accommodation for up to 24 older people. There are 16 single and four double bedrooms, with five of the bedrooms having the provision of en-suite toilets. A passenger lift to the first floor is provided. There is a small garden and patio area to the rear and car parking is also available.
We last inspected this service on 4 August 2014 and found that the service was compliant in the regulations we assessed.
The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People who used the service and the visitors we asked told us that Belvoir Care Home was a safe place to live and they were well looked after. Staffing levels were sufficient to meet the needs of people who used the service.
Safeguarding procedures were robust and members of staff understood their role in safeguarding vulnerable people from harm.
We found that recruitment procedures were thorough and protected people from the employment of unsuitable staff.
The home was clean and appropriate procedures were in place for the prevention and control of infection.
Members of staff told us they were supported by management and received regular training to ensure they had the skills and knowledge to provide effective care for people who used the service.
Members of staff had also been trained in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) so they knew when an application to protect a person’s best interests should be made and how to submit one.
Most of the people we asked told us the meals were good. Snacks and drinks were available between meals. We found that people’s weight and nutrition was monitored so that prompt action could be taken if any problems were identified.
People were registered with a GP and had access to a full range of other health and social care professionals.
We saw that members of staff were courteous and treated people with respect. People who used the service were nicely dressed and looked smart.
We saw that care plans included information about people’s personal preferences which enabled staff to provide care that was person centred and promoted people’s dignity and independence.
Some leisure activities were organised within the home. These included games such as dominoes and draughts and reminiscence.
A copy of the complaint’s procedure was displayed near the main entrance. No complaints had been made to CQC or the local authority during the last year.
Members of staff told us they liked working at the home and found the registered manager approachable and supportive.
People who used the service and their representatives told us the home was well managed and would recommend it to others.
We saw that systems were in place for the registered manager to monitor the quality and safety of the care provided.
Is the service safe?
Is the service effective?
Is the service caring?
Is the service responsive?
Is the service well led?
This is a summary of what we found-
Is the service safe?
We spoke with two people who used the service and they both told us they were happy and felt safe living at Belvoir care home. Staff members had completed appropriate training related to safeguarding vulnerable adults which helped ensure people were kept safe at the care home. Staff members we spoke with told us they knew what to do in the event of any allegations of abuse and would not hesitate to report them to the manager.
The care home was clean and hygienic and equipment was serviced and maintained regularly. This helped ensure people who used the service were not put at any unnecessary risk.
Deprivation of Liberty Safeguards (DoLS) become important when a person is judged to lack the capacity to make an informed decision related to their care and treatment. The provider told us no recent applications for DoLS had been made but knew the procedure to be followed if an application needed to be made. At the time of our inspection, no person who used the service was subject to a DoLS.
Is the service effective?
There was an advocacy service available for people who used the service. This helped ensure that if people required additional support, they could, or would be supported, to access it.
People`s needs had been taken into account with the signage and layout of the care home. This meant people could move around the home safely and freely. The home had been sensitively adapted to meet the needs of people with limited mobility which promoted their independence.
Is the service caring?
People who used the service were supported by staff members in a patient and unhurried manner. Staff gave encouragement to people but supported them if they thought assistance was required.
People and when possible, their families were involved in regular meetings and completed surveys. This provided them with the opportunity to express their views related to how their care and support was provided. One person told us, "Once you come here you don`t want to leave."
Is the service responsive?
During our inspection, we observed people taking part in several activities during the day. We were told of social outings that had been attended by people who use the service. One person told us, "We went to a place near Blackpool and we had a lovely time. We have been promised another day out soon."
People we spoke with and family visitors knew how to make a complaint if necessary. We looked at the last complaint received and saw it had been managed in accordance with the provider`s policy.
Is the service well led?
We saw evidence that the provider had procedures in place that monitored the quality of service being provided to people who used the service. This helped ensure the service continued to improve.
We saw records of GP and other professional visits. The provider told us they worked well with, and had a good relationship with other agencies. This helped ensure people received care and support when they needed it.
We saw that people enjoyed a good rapport with staff. People were encouraged to be as independent as possible and where necessary, were assisted in a gentle and unhurried way.
People who we spoke with told us, 'They regularly check on me to make sure I'm alright, they always answer the bell' and 'My routine is very flexible, they [the staff] are very accommodating'.
Individual care records were in place directing staff in the delivery of care. These could be enhanced with more personal information about people's preferences and how they would wish to be cared for.
Suitable arrangements were in place with regards to safeguarding and protecting the rights of people.
Suitable arrangements were in place when recruiting new staff. Adequate staffing levels were available to support people. These were kept under review depending on the care and support people needed.
Staff spoken with told us that there were sufficient staff available to support people. They said they would speak with the manager if they had any concerns and felt supported in their role.
Systems to monitor and review the quality of service provided had been developed. This information helped to identify where the service could be improved further.
We saw that staff were very attentive and patient with people. Explanations and reassurance were provided when offering support and assistance. People appeared to enjoy polite conversation with each other and staff in a relaxed environment.
We also spoke with people living at the home and their visitors. They told us; 'I'm very happy here, give them 10 out of 10', 'The foods great, plenty to eat' and 'The staff are wonderful, plenty of time for visitors too, always make us welcome'.
Other comments included; 'I've no complaints at all', 'You won't find anything wrong here', 'I'm safe here, I feel safe', 'They are really kind' and 'They do more than their best'.
Visitors also commented, 'they keep in contact if I need to know anything', 'They always look after us when we visit' and 'Nothing is too much trouble'.
People spoken with told us; 'They (the staff) are very kind', 'The food is nice, you get a choice', 'I can go to bed when I want', 'I'm looking forward to Christmas, it's my first here', 'Yes, we do activities, I like the knitting and crafts' and ' I've made some friends since moving here'.
We also spoke with a number of visitors to the home. They too were very positive about the staff and care provided. They told us; 'It's a wonderful home', 'The carers are wonderful', 'They are so kind' and 'We're always made welcome'.
Interactions between people and staff were pleasant, eye contact was made, language was kind and encouraging and people seemed to enjoy laughing and chatting with staff.
One visitor told us 'My relative is in such good health, we can only put it down to the good care they receive'.
Other comments included; 'I've never had any cause for concern', 'They've done a lot of work on the home', 'It's a homely home' and 'They will do things for you, if you can't manage yourself'.