We carried out a review of the data available to us about BELVOIR HOUSE CARE HOME 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 HOUSE CARE HOME, you can give feedback on this service.
Belvoir House Care Home is a residential care home providing personal care to up to 24 people. The service provides support to adults, some of whom may be living with dementia. At the time of our inspection there were 19 people using the service.
Belvoir House Care Home is in an adapted building over three floors.
People’s experience of using this service and what we found
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.
Staff were safely recruited and there were enough staff to meet people’s needs. Staff had received training in how to provide safe care to people and knew how to report concerns about people’s safety.
Risks were safely managed in the home. Medicines were safely stored and administered to people in line with their prescriptions. The home was clean and infection control processes were in place to reduce the risk of infection.
Audits in the home were effective in monitoring the quality of care provided and driving improvements. Surveys were used to gather the views of people at the home and the information was also used to drive improvements in care.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (8 June 2021).
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
The inspection was prompted in part due to concerns received about medicines and the assessment of risk. A decision was made for us to inspect and examine those risks. We also followed up breaches of legal requirements found at their last inspection relating to the safe care and treatment and the governance in the home. This was to check they had followed their action plan and to confirm they now met legal requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Belvoir House Care Home. on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Belvoir House Care home is a residential care home providing personal care to 19 adults, some of who may be living with dementia, at the time of the inspection. The service can support up to 24 people.
People’s experience of using this service and what we found
At times staff did not adhere to good practice guidelines on wearing personal protective equipment.
Risks to people while they received care had been identified. However, care was not always planned to keep people safe and care plans contained conflicting information on how to care for people safely. On occasion, staff deployment impacted on their ability to monitor people’s safety.
Staff had been trained in how to keep people safe from abuse and the acting manager worked with other healthcare professionals to improve the safety of care provided.
The registered manager had been away from the home for a prolonged period. The acting manager ensured that the service continued to support people. However, audits to monitor the quality of care provided had not been completed.
Relatives were happy to raise concerns with the acting manager and were confident action would be taken to improve the quality of care provided.
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 7 May 2020).
Why we inspected
The inspection was prompted in part due to concerns received about infection control and the registered manager being sick for a prolonged period due to COVID-19. 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. The provider did take action to resolve some of the concerns identified.
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 monitor the service. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Belvoir House Care Home currently accommodates 18 people in one adapted building. There are three bedrooms which can accommodate couples or friends who wish to be together. The accommodation is split over three floors, with communal areas on the ground floor.
People’s experience of using this service and what we found.
There were systems in place to ensure that people were protected from abuse and avoidable harm. Staff knew what these systems were and how to access them. People told us that they felt their relatives were “safe and happy”.
People told us there were enough staff to ensure they could have all their identified needs met, both day and night. People always knew the staff looking after them and they reported .they were well and kindly treated.
People are supported appropriately to eat and drink, with a variety of balanced diets available and a pleasant eating environment is provided .
Staff received training and supervision to help with their development and confidence when supporting people. They knew people well and were knowledgeable about when to refer to other health professionals for advice and support.
Staff communicated easily and comfortably with people, in a reassuring manner. One Community Nurse told us they had looked after her relative and the care “was second to none”
Managers and staff are clear about their roles; they understood risks and regulatory requirements
Improved quality monitoring systems had been introduced and identified where improvements were
needed. Action plans were in place to monitor these .
The provider and registered manager promoted a very person-centred culture which respected people's
diversity. Meetings were held with people, relatives and staff to exchange information and gather feedback.
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
The last rating for this service was Requires improvement (published 13 February 2019).
Why we inspected
This was a planned inspection based on the previous rating.
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Belvoir House Care Home is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Belvoir House Care Home provides accommodation for up to 24 people living in one adapted building. The home provides care for older people some of who may be living with dementia. There were 20 people living at the home when we inspected.
There was no registered manager in post at the time of our 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.
This was the first inspection of the home since the provider purchased it. Therefore, this is the first time the home has been rated Requires Improvement.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
Care plans contained the information needed to support staff to provide care tailored to people’s individual needs. They also contained the risk assessments to minimise the risk to people while receiving care. However, pressure care was not always provided in line with the risk assessments. People received coordinated care at the end of their lives as the staff worked with healthcare professionals to ensure people received the care needed at this time of their lives.
The number of staff needed to care for people was assessed but due to sickness people were late receiving their care. Recruitment processes ensured that staff were safe to work with people living at the home. Staff received the training and support needed to provide safe effective care. Policies were in place to support effective care. Staff knew how to keep people safe from the risk of abuse.
People were offered a choice of meals and were supported to eat safely and maintain a healthy weight. Medicines had not always been available to people and recording of medicines did not always support the safe management of medicines. The home was clean and staff knew how to use protective equipment to keep people safe from the risk of infection.
Staff were kind and caring and took the time to get to know people. They offered people choices in their lives and involved people in their care. People’s ability to make decisions was assessed. However, when people had arranged for others to make decision on their behalf the paperwork to confirm this was not available. At times people’s dignity was not maintained. Activities were provided, however at times the activities may not be supportive of people living with dementia.
Systems to monitor the care people received had not identified the concerns around the management of medicines. However, they had identified all the other concerns we found. In addition, complaints and incidents had been investigated and action had been taken to improve the safety and quality of care provided. The environment did not support the needs of people living with dementia and was not maintained to an acceptable standard. In addition, linen in the home was in poor condition.