Belvedere House

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 good. At this assessment the rating has changed to 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 breach of legal regulation in relation to people’s safe care and treatment.
 

This service scored 62 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.

We asked staff how they recorded accidents and incidents and escalated safety concerns. One staff member told us, “First I will write them in my notes on [system name] and then I will speak to a nurse and if it’s very urgent I will go to the manager.” Another said, “I’ve never seen any safety concerns. I am aware of what happens here and I would know but we all look out for each other and there’s never been any concerns.”

The registered manager told us internal investigations were carried out following incidents and were reported to the local authority where required. They told us they took time to investigate complaints to ensure all relevant information was considered before reaching a conclusion. The outcome was shared with staff for learning and making improvements. This reduced the risk of similar concerns occurring.
 

The provider collaborated 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.

People experienced a planned transition into the service and staff demonstrated the admissions process supported a smooth transition to help people settle into their new home. A relative told us, “Mum had a stroke and she was first in another home. [Name] did an amazing job of interviewing my mum and arranging to get my mum in here as at that point there weren’t many rooms. She calls this her home now. It’s like a second home for me too. Everyone I speak to can’t rate it enough and everyone wants to move in.”

Staff told us, “If a new resident comes today, I will ask the resident /relative about them including what they like and dislike. This information will be passed to all staff as we write this down and we have teams’ meetings where new residents are discussed.”

Following completion of a pre-assessment, the clinician notified relevant departments and circulated a form containing information about the person and instructions for staff. This supported communication between teams and helped ensure people received a coordinated welcome and their needs were considered on admission.

The registered manager said staff used a specific hospital referral form to provide relevant information and improve transparency. They followed up information after discharge and contacted hospitals directly if information had not been fully communicated.
 

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 can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found DoLS authorisations were appropriately applied for and overseen. These assessments helped to ensure decisions are made lawfully and in the person's best interests when they lack capacity.

The provider had systems to protect people from unauthorised access. Visitors were monitored electronically, and professionals or contractors without DBS checks were escorted on site. Access to the dementia wing was restricted by a security code shared on a need-to-know basis. Staff were informed of contractor visits to help ensure access was limited to authorised areas.

Staff told us they felt confident raising safeguarding concerns. One staff member told us, “The management will conduct their investigation and if, for example, the abuse involves a staff, then the staff will be suspended whilst the investigation is ongoing. I’m very comfortable to raise any abuse concerns as action is taken straight away.” Another said, “There isn’t really anything to raise concerns about. We all look out for each other.” A relative told us, “Mum is very safe at Belvedere house” describing the service as a, “lovely place and very safe.”

Staff confirmed they received safeguarding training. One staff member told us, “We have safeguarding training every year. It’s very useful for my role.” Staff said they found the training particularly useful in supporting people living with dementia. Regular safeguarding training supported staff to understand their responsibilities and respond appropriately to people’s individual needs.
 

The provider did not always work effectively with people to understand and manage risks. Incomplete risk assessments and inconsistent monitoring records meant staff did not always have access to accurate information to support safe care.

One person’s care plan and risk assessment suggested they pick up objects and put them in their mouth. Information regarding the person's tendency to place cutlery or napkins in their mouth during mealtimes was not recorded in their care plan. This was only clarified by the registered manager during the inspection and was therefore not available within the person's documented care records. Following our discussion, the registered manager provided an updated care plan which included this information.

We identified risks associated with catheter self-care and fluid intake. One person was self-caring in relation to their catheter. Although there was a catheter care plan, there was no associated risk assessment. This increased the risk that catheter-related complications may not be identified or responded to promptly.

Despite being told that people who had catheters were on a fluid chart, this was not always the case. One person did not have a fluid chart and staff were not recording their fluid intake robustly in their daily notes. Another person had notes in their care plan about fluid intake, but there was no evidence that there was a separate fluid chart. Records were held both electronically and on paper systems. This increased the risk that reduced fluid intake or changes in urine output would not be identified promptly. The lack of consistent records resulted in staff not always having access to accurate information to identify deterioration.

During discussions regarding these concerns, the registered manager informed us they had recognised some of these concerns and were exploring improvements in systems and recording practices to strengthen the management of the risk. The existing system presented challenges in recording fluid intake information effectively. They advised that they are exploring the implementation of a more efficient system that would be easier for staff to use.
 

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

Staff told us there was a maintenance manager responsible for responding to concerns about faulty equipment. They said any reported faults were acted on straight away. Staff also told us there was sufficient equipment to support people safely and reduce the risk of people waiting for assistance.

We found evidence of regular checks to monitor the safety of the premises and equipment. There was an up to date fire assessment. Vehicle safety checklists were in place and first aid equipment was checked monthly, with records showing that supplies were replenished when required.

Legionella checks were completed across the service, including plant rooms, sluice rooms, laundry, kitchen, bathrooms, staff rooms and individual bedrooms. Equipment checks were also completed covering bed rail, shower chairs, trolleys and feeding tables, with checks recorded against individual rooms.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

The registered manager told us there were no current recruitment issues and staffing arrangements were sufficient to meet the needs of the home. This information was consistent with observations during the inspection. One person told us, “They don’t rush me here. There are enough staff more or less.” A relative said, “They seem to have enough staff. They don’t appear to be rushed.”

We observed staff throughout the day and saw they were available to respond to people's needs in a timely way. Staff told us staffing levels were sufficient to meet people's needs and that they had enough time to provide support at mealtimes without feeling rushed. Staff were deployed effectively, with those requiring more time to support people with eating allocated to provide this support, while other staff assisted in the dining area and served meals. One staff member told us, “There’s no rush as we have enough staff.”

We asked staff about the induction they received when they started working at the service. One staff member told us, “I did my induction 5 years ago and I did 1 month of induction where I completed shadowing and went to resident rooms as well with an experienced staff member. I also completed online training. The induction was good for my role.”

The provider offered a range of mandatory and additional training opportunities to support staff in carrying out their roles safely and effectively. One staff member told us, “We have the opportunity to ask for more training if needed but I have enough here. There’s also support available here. It makes you more aware of your role.”
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

The environment was clean, well-presented and free from unpleasant odours. Sluice rooms (areas dedicated to cleaning soiled items or disposing of clinical waste) were clean and tidy with no odours noted.

The service had effective arrangements for the management of laundry with separate clean and dirty areas. Staff demonstrated how heavily soiled items were placed into red bags and processed in a dedicated washing machine. Other laundry was appropriately segregated and processed using the other washing machines before being transferred to the drying area. The laundry was clean, uncluttered and well organised with sufficient space, lighting and equipment to support effective infection prevention and control (IPC). Laundry staff told us there were sufficient staff to meet the needs of the service.

Staff demonstrated an understanding of when personal protective equipment (PPE) should be used and how it should be disposed of. One staff member told us, “We have a PPE storage room and will dispose of it in that room and tie it up in a bag and then put it in the bin in that storage room. There’s enough PPE.”
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People were not consistently protected from the risks associated with medicines because medicines management systems were not always effective. We identified a number of concerns, including expired medicines, failures to act on clinical instructions, inaccurate medicines records and insufficient recording of PRN medicines. These issues had not been identified through the provider's medicines auditing processes, despite a range of monitoring arrangements being in place. This reduced assurance that medicines were being managed safely and in accordance with people's needs, clinical instructions and best practice.

We found 8 expired medicines, including oral sprays.. The expired medicines were discarded immediately when brought to the nurse’s attention.

A hospital letter instructed that 1 person’s pain patch (medicine in patch form) should be stopped. However, the patches continued until this was raised during the inspection. The registered manager subsequently investigated this and confirmed arrangements with the GP for alternative treatment. The registered manager told us that moving forward, clinical letters received by the service would be acted upon immediately, including stopping medicines when instructed, rather than waiting for the GP to visit.

We also found discrepancies between a pain patch body map and the person’s medication administration record. The body map indicated a 21-day change interval on a particular month, while the medication record stated 7-day changes for the same month. The registered manager confirmed the patches were changed every 7 days. In addition, 1 person’s care plan relating to daily medicine for seizure activity could not be located by a nurse during the inspection. The care plan was provided after the inspection and confirmed the medicine was administered correctly.

Where people were on PRN medicines (medicine as needed) these had been administered without a contemporaneous record of the reason or outcome. This meant staff could not demonstrate why medicines had been given or whether they had been effective. The information was added and shared after the inspection.

These shortfalls had occurred despite the registered manager telling us they had a dedicated medication nurse who was responsible for medicines audits and reordering, a monthly medication task list and monthly medicines audits undertaken. External clinicians were also contracted to review audits twice a year. The registered manager acknowledged that maintaining constant oversight was difficult and was taking steps to introduce senior nurse and senior carer roles to take on additional responsibilities.

People and relatives told us that medicines were managed correctly. One person told us, “I do take my medication. The staff do it for me and they do it correct.” A relative told us, “He is on medication and it’s done properly.”