• Care Home
  • Care home

Bellsgrove Care Home

Overall: Requires improvement read more about inspection ratings

250 Cobham Road, Fetcham, Leatherhead, Surrey, KT22 9JF (01372) 379596

Provided and run by:
Mr & Mrs S Logathas

Latest inspection summary

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Background to this inspection

Updated 11 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by two inspectors. We also had an Expert by Experience who made telephone calls to family members. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Bellsgrove Care Home is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Bellsgrove Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with two people who used the service and one relative about their experience of the care provided. We also spoke with a healthcare professional and three members of staff including the registered manager.

We reviewed a range of records. This included eight people’s care records and multiple medication records. We looked at five staff files in relation to registration, recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

After the inspection

Following our visit to the service, we spoke with eight family members on the telephone. We continued to seek clarification from the provider to validate evidence found.

Overall inspection

Requires improvement

Updated 11 August 2022

About the service

Bellsgrove Care Home is a residential care home providing personal care and accommodation for up to 15 older people including those who live with dementia. The service is set over three floors and has a communal lounge area and dining area on the ground floor. A lift connects all levels. At the time of the inspection 15 people were living at the home.

People’s experience of using this service and what we found

Risks associated with people's care were not always assessed in a safe way, particularly in relation to the use of bed rails and supporting people to eat. People and their relatives told us they felt safe and we checked that the provider had systems in place to ensure safe recruitment of staff. Staff followed good infection prevention and control practices. There were sufficient staff, however, we have made a recommendation that staff are efficiently deployed in order to engage with a people who remain in their rooms.

We found that the environment did not meet the needs of people who lived with dementia. Some people told us activities were not varied enough and the activities we observed did not always serve to engage those with more profound dementia, especially those who remained in their rooms for periods of time.

The provider did not always ensure that people accessed healthcare professionals in a timely manner. 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.

Quality assurance processes were not effective in identifying and delivering required improvements to the service which meant people were at risk of not receiving a consistent or safe service in line with their needs. There was a lack of robust management oversight of the service.

Staff told us there was good teamwork amongst the care staff but some said they did not always feel valued by the provider. Family members told us the registered manager was approachable and available to them and that there was a friendly and homely atmosphere at Bellsgrove.

People and their family members told us that staff were consistently respectful, kind and caring and we observed how staff engaged with people in a warm and friendly way. People’s needs were assessed prior to moving into Bellsgrove Care Home. Care plans were detailed and staff knew how to support people according to their wishes.

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

We carried out a focused inspection on 14 February 2021 when this service was rated requires improvement (published 21 January 2021) and there were breaches of regulation. 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 the provider had not made enough improvement and remained in breach of regulations. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This inspection was carried out to check if the provider had followed their action plan and to confirm they now met legal requirements.

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.

Enforcement and Recommendations

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 and will take further action if needed.

We have identified breaches in relation to assessment of risk, medicines management, timely access to healthcare professionals, environmental design, lack of meaningful activities and governance of 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 continue to monitor information we receive about the service, which will help inform when we next inspect.