Belgravia Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 54 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us they felt supported and involved in improving the service and they considered they worked well as a team. The registered manager supported staff to understand the aim of the service, which was to deliver good care which met people’s needs and promoted their rights.

People told us the registered manager spent time with them gaining their views and wanted to improve the service provided. They told us the provider and registered manager promoted teamworking. Comments we received included, “Without a team we’re nothing.” And, “I’m very comfortable talking to any of the management, they all listen, and we work together as a team.”

Leaders did not always have the skills, knowledge, and experience to lead effectively.

We saw repeated concerns from our previous assessment which had not been rectified and in addition, we identified further shortfalls which have been identified in this report.

However, the provider employed a registered manager who worked with other stakeholders, people and relatives to shape the service and deliver care. People said the registered manager was approachable and engaged with them. They shared the manager was available if they needed to speak with them on an individual basis.

Staff spoke positively about the provider and the management team. Staff said they felt supported, and they were able to discuss any concerns they had with them.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us the management team were available during the day and also in the evenings, nights and weekends. There was an on-call system in place where staff could contact a member of the management team if advice was needed. Staff told us they were confident to speak up and believed appropriate action would be taken.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had a supportive culture which valued staff.

Staff told us they felt valued and were confident the registered manager and provider promoted inclusion and equity. Staff could give examples of how their individuality was recognised and their rights upheld.

The provider did not always have effective systems in place to drive improvement.

At the last assessment we found significant shortfalls which had not been identified in the audits completed. At this assessment we found audits did not consistently identify shortfalls and improvements were not always made. For example, we found the kitchen was unclean, the room temperature where the medicines were kept was not being monitored and 2 care records required further information to guide staff when and how they should provide responsive care. These shortfalls had not been identified through formal and informal audits and checks.

Before the assessment concluded, the operations manager shared a quarterly audit they were planning to introduce. This was a range of detailed checks which would support and drive improvement.

The provider understood their duty to work in partnership, so services worked seamlessly for people.

The provider and registered manager were working with external stakeholders to improve the service and told us they welcomed any guidance and support that would positively impact people’s experience. For example, the provider was taking action to improve fire safety at the service. We spoke with a visiting health professional who told us the service worked well with them and provided all essential information so timely decisions could be made about people’s care and support needs. A staff member commented, “We’re lucky to have such good relationships with the nurses and care home team.” This showed staff valued and respected the support from other health professionals.

The provider did not have effective processes in place to support continuous learning, innovation and improvement across the service.

The provider did not always have effective systems in place to drive improvement and support learning. At the last assessment we found significant shortfalls which had not been identified in the audits. At this assessment we found that the audit systems had not identified the concerns we found. We discussed this with the operations manager who said they were in the process of introducing a three-monthly audit to help drive improvement. However, this was not being used at the time of the assessment.

Staff spoken with said the management team would listen to them and make improvements if this was required.