Belvedere House

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 good. At this assessment the rating has changed to 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 breach of legal regulation in relation to good governance and notifying us of incidents.
 

This service scored 61 (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.

The registered manager told us the key values of the service and the strategic goals were, “Professionalism, responsibility and accountability, and family and homely feeling.” They explained these values reflected their reasons for working at the service and the culture they wanted to promote for people and staff.

Staff demonstrated the home’s values in practice and contributed to a warm, family-oriented and homely atmosphere, We observed during an activity, residents were singing along to familiar songs performed by a visiting singer, with staff actively joining in by singing, clapping, holding resident’s hands and dancing alongside them. This demonstrated a positive and inclusive culture where staff actively engaged with residents and supported meaningful social interaction and enjoyment.

The registered manager communicated the service’s expectations and values through regular staff meetings, messages, an open-door policy and weekly audits. Staff were supported through induction, training, coaching and mentoring, which the registered manager described as key methods for promoting the service's values.

Leaders were experienced and understood the context in which the provider delivered care, treatment and support. However, there was some inconsistency in their understanding of their requirements of registration.

The registered manager had experience managing the service; however, we identified gaps in their understanding of notification requirements. We found that notifications were not always submitted to CQC in line with their legal requirements of registration. This included an incident where 1 person hit another on the leg with a walking stick, and another person was involved in sexual abuse on 2 separate occasions. This meant CQC was not always informed of incidents and concerns that met the threshold for notification. However, the registered manager had reported the incidents to the local authority and had submitted other safeguarding notifications appropriately.

Following discussion during the assessment, the registered manager acknowledged the shortfalls identified and provided assurances that notification processes would be reviewed to ensure future incidents were assessed and reported in line with regulatory requirements.

In other aspects the registered manager displayed a good oversight of the service, encouraged staff wellbeing, valued diversity and focused on collaboration and partnerships with the community.

Staff spoke well of the leadership team and told us, “The manager is very approachable and they’re all lovely people. If any entertainers come in then the managers will join in as well as the staff. We all become one. I would like to live here when I’m older” and “They are really good. They will ask for our opinion and will always help us when needed. There’s no stress here.”
 

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

Staff told us they were able to approach management with concerns and described an open-door approach. One staff member told us, “I am able to go to management with any issues and the door is always open for us. [Registered manager] and [deputy manager] always listen to me.”

The registered manager said staff who raised concerns were encouraged to be open. They could raise concerns directly with management through online forms or use written forms if they did not feel comfortable speaking face to face.

The registered manager said concerns would be discussed with the staff member, investigated and addressed. The registered manager told us learning from concerns was shared with staff to help prevent similar issues occurring.
 

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.

Staff said they felt equally treated with 1 telling us, “We are all treated equally. They never show that they like certain staff or they don’t like certain staff. There has never been any issue of discrimination.”

The registered manager said there was no place for bullying, shouting or abuse towards staff or people using the service and that staff understood these expectations. They described the workforce as multicultural and told us they encouraged staff to understand and respect different cultures. This included holding celebratory days to promote awareness and understanding of cultural diversity within the team.

The registered manager told us some staff had additional support needs and it was important to them these staff felt accepted within the service. The registered manager described how staff with additional support needs were supported and encouraged to feel accepted within the service.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider's governance systems had not consistently identified or acted on concerns relating to notifications, capacity assessments and decision-making records. This included ensuring notifiable incidents were consistently identified and reported to CQC in accordance with statutory notification requirements, and arrangements for monitoring whether people’s capacity, consent and decision-making rights were appropriately considered and recorded.

Care plans lacked sufficient person-centred detail and guidance for staff, and governance systems had not consistently identified or addressed these shortfalls.

We also found that governance arrangements had not identified the shortfalls in medicines practices which we identified.

As a result, opportunities to address concerns through routine monitoring, auditing and management oversight had been missed. The lack of effective oversight reduced assurance that the provider had sufficient systems to monitor the quality and safety of care and drive sustained improvement.
 

The provider worked with a range of external partners and community organisations to support people and promote community engagement.

The service worked with external partners and included working closely with GPs and Speech and Language Therapy (SaLT), They worked with the British Legion and the NHS to host a monthly memory café. The café was open to people living at the service and members of the local community. Volunteers from the local community, including tenants and relatives, also supported the service.

Sunday coffee mornings were held for residents and relatives to meet, connect and share ideas. The registered manager told us they deliberately did not attend these meetings so people could speak openly about the service and management if they wished.

It was part of the Veteran Friendly Group and staff also worked with Music in Hospitals to explore the positive impact of music on people.
 

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Although the registered manager was keen to learn, improve the service and provide the best care for people, they had failed to identify the shortfalls and areas requiring improvements which we highlighted during our visit. It was only when we alerted them to these that they took action. This included medicines practices and processes, the lack of capacity assessments and best interests decisions and the failure to hold robust documentation. This showed the registered manager had not identified these concerns through existing oversight processes and only took action after they were highlighted during the assessment.

The registered manager has taken proactive steps to strengthen management oversight within the service. Training has been arranged for all nursing staff and the deputy clinical lead to further develop their knowledge and practice in relation to medication management. The registered manager and deputy will undertake daily spot checks to monitor practice, identify any areas requiring improvement and ensure learning is embedded consistently. These measures were introduced to strengthen oversight and improve medication management practices.