Belgravia Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in continued breach of legal regulation in relation to governance at the service.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive culture of safety. Lessons were not always learnt to continually identify and embed good practice. We saw repeated concerns from our previous assessment which have been identified in this report. For example, audits had not identified areas that required improvement.

However, staff we spoke with knew how to report accidents and incidents and why this should be done. Staff told us if changes were needed to people’s care, this was passed to them through handovers and discussions, and investigations were carried out to identify whether there were any lessons to be learned.

We saw accident and incident forms were completed and the deputy manager told us these were reviewed to identify any themes or trends. For example, a door to a person’s room was fitted with a door sensor. This sounded an alarm when the person opened the door. This alerted staff that the person was leaving their room so they could help them. This minimised the risk of accidents and incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Prior to people moving into the service, a pre-admission assessment was carried out to ensure the service could meet people’s needs. People told us if they needed support from a health professional, this was arranged and documentation we saw evidenced this.

Information was provided to health professionals to inform clinical decision making. For example, if a person needed to go to hospital in an emergency, written information was provided. This helped communicate essential information to staff who may be unfamiliar with the person’s needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe. One person commented, “I am very happy here and safe. That’s because someone is always here.” Staff were able to confidently explain the reasons they may make a safeguarding referral to the safeguarding authority and how they would do this. One staff member commented, “Any safeguardings are escalated quickly, we’ve had training in it and know how to report.”

Deprivation of Liberty Safeguards (DoLS) applications were submitted appropriately. Mental capacity assessments were carried out and best interest meetings were documented. This helped ensure any restrictions were lawful.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments identified whether people were at risk of falls, malnutrition and to assess the risk of people developing pressure damage to their skin. These were reviewed when required and risk controls were in place if needed. For example, we saw a care record which described the equipment needed to help the person maintain their safety. The person told us they felt safer with the equipment, and they liked having it. A relative commented, “I think it’s safe. They’ve always looked after (my family member) well.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Equipment was serviced to help ensure it was safe to use, and windows were fitted with restrictors if there was a risk of falling from them. We saw evidence that fire equipment, gas servicing, lifting equipment and electrical safety checks were completed as required by regulation.

People were provided with portable alarms. These helped ensure people could summon assistance if they needed it. For example, we saw some people liked to sit outside the home and they were given a portable pendant in case they needed assistance and to summon staff when they wanted to re-enter the home.

The provider was making improvements to the fire safety controls at the service; we saw work was being carried out to ensure all relevant fire regulations would be met.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

The provider used a dependency tool to help assess the number of staff required to support people. However, this did not consider that a member of care staff was required to cook and serve meals or that the location of the dining room had temporarily changed meaning it took longer to take meals from the kitchen to the dining room. On the first day of the assessment, we saw staff were rushed and people could not be assured they would have their needs met promptly. We discussed this with the registered manager and on the second day of the assessment an additional staff member had been deployed to work in the kitchen. We saw people were supported quickly and staff told us they now had more time to spend with people.

The provider followed recruitment procedures to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

Staff told us they had regular training, and an induction was in place to support staff who were new to the service. One staff member commented, “We get plenty of training.” Staff also said they had regular supervision and appraisals. They said these were useful and enabled them to discuss training, their performance, and any concerns they had. They told us this was a supportive process which enabled them to spend time with management on a one-to-one basis.

The provider did not manage the risk of infection. They did not always detect and control the risk of it spreading.

We found the kitchen where food was stored, prepared and cooked was unclean with a build-up of dust, and marking on shelves and windowsills. The fridge temperature was higher than the recommended legal maximum required by the Food Standards Agency. The microwave required cleaning, there was a crack on the internal roof of it, and we found some catering equipment was unclean. We raised our concerns with the Food Standards Agency for their consideration.

The communal shower room contained bathing equipment that required cleaning, and an ensuite bathroom had a build-up of matter on the shower door sliders and a build-up of what appeared to be limescale in the toilet. This does not promote a hygienic environment and could impact effective cleaning. We raised our concerns with the Local Authority Infection Prevention and Control Team.

The provider responded swiftly to our concerns. Prior to the assessment concluding we saw the kitchen and equipment in the communal shower room had been cleaned and the fridge and microwave had been replaced. Following the site visit the provider contacted us and told us they had increased checks on cleanliness and were supporting staff to understand the standards required.

Staff had access to personal protective equipment, and we observed staff using this appropriately.

The provider did not always make sure that medicines and treatments were stored safely and records were an accurate reflection of medicines available.

Medicines were not always stored safely. Staff did not monitor the temperature of the room where medicines were stored. This had been identified at the last assessment. This posed the risk that medicines may be stored outside the temperature zones of the manufacturers recommendations and their efficacy could be reduced.

The provider had an electronic medicines management process. The totals of some medicines on the electronic records did not match the totals of medicines available. The provider carried out an immediate investigation and it was confirmed there was an error on the electronic system. However, the discrepancy in records and totals had not been identified through effective oversight.

Medicines were disposed of safely and staff had received training in the safe management of medicines. Competency assessments were carried out to ensure staff were competent. We observed medicines being administered in a discreet and safe way.