Bellsgrove 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. We also identified a breach of Regulation 12 (Safe care and treatment). At this assessment the rating has changed to Good and the service was no longer in breach of Regulation 12.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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 culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The registered manager told us, “We tend to share information at staff meetings, and at supervisions if things needed to be discussed as a one to one. If there are things that staff have said they’re not too sure on, then I will try and do little sessions and check understanding.” The provider’s accidents and incidents folder was organised and included a clear description of what happened, who was informed, and any remedial action taken.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff were aware of their responsibility to safeguard people from abuse. 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 registered manager confirmed that the theme of safeguarding was discussed during staff meeting and supervisions. Information around safeguarding and who to contact with any concerns was displayed on the notice board within the office. The provider shared concerns quickly and appropriately with the local authority and the Care Quality Commission (CQC).

People and their relatives confirmed they felt safe at Bellsgrove. One person told us, “I don’t worry about anything. I am happy here.” Another person confirmed, “I do feel safe here. They are nice. They make me feel safe.” A relative told us, “The staff are attentive, and they genuinely appear to care about [person’s] wellbeing. I've never experienced any negative behaviour from the staff.”

Decision specific mental capacity assessments were in place to record if a person lacked capacity in certain aspects of their life, such as medicines or finances. Best interest decisions had been held with those who were involved in people’s care to ensure the least restrictive option had been chosen to support the person. Furthermore, applications for Deprivation of Liberty Safeguards (DoLS) had been made to the local authority where needed. These allow lawful restrictions to be put in place in order to keep someone who lacks mental capacity safe. Staff were aware of the principles of the Mental Capacity Act 2005, and how this affected how they delivered care to people.

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. Care plans included risk assessments on how to manage individual risks to people. For example, one person was at high risk of falls and required a sensor mat to be placed on the floor in front of the chair they were sitting on in the lounge. We observed this was in place. Another person was at risk of malnutrition and weight loss. Staff were ensuring they were being given high calorie snacks and drinks throughout the day.

Relatives also confirmed they felt staff managed risks safely. One relative told us, “When [person] was more mobile she did experience some falls, and the home put steps in place to try and avoid these with pressure mats and moving her downstairs so as to be able to keep a better watch when she refused to leave her room.” This had effectively minimised the risk of the person falling.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. For example, the laundry room was always locked due to it containing chemicals that could be dangerous if ingested, and there were no trip hazards around the environment such as trailing cables. The registered manager confirmed, “We’re looking to do some improvements, such as new flooring upstairs in one of the rooms. Possibly more cosmetic updating too.”

The provider made sure there were enough qualified and experienced staff, who received support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, there had been a recent incident which was still under investigation. This had identified a lack in basic first aid awareness amongst staff. The provider had ensured following the incident that all staff had received face to face first aid training.

On the whole, staff were up to date with all other training modules. The registered manager told us, “Training is mostly up to date. We’ve had a recent push on this.” Staff felt able to request further training if they required it. For example, one staff member told us, “We did [moving and handling training] but I don’t feel confident with it. I have told the registered manager, and she will arrange something.”

We observed call bells were responded to in a timely manner, and staff were not rushed and had time to engage with people. One person said, “There are always staff around, and it’s reassuring.” The registered manager confirmed, “We haven’t gone below safe staffing levels. Staff are good for stepping in and are local and we’ll ask them to cover if there’s sickness which they will do.”

Staff were recruited safely. Recruitment checks included ensuring applicants had no unexplained gaps in their employment and had a disclosure barring service (DBS) check. This ensures applicants were of good character and safe to work with vulnerable people.

The provider assessed and managed the risk of infection. The service was clean with no malodours. One relative told us, “It’s always clean and [person’s] bed is clean and made every time I go.” There were regular monthly infection control audits carried out. These included if staff had completed infection control training, if staff followed hand washing procedures, and use and disposal of personal protective equipment (PPE). Where shortfalls were identified we saw appropriate action was taken. For example, one staff member had failed a module of infection control training and was supported to re-do the necessary training.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Each person had a ‘medication profile’ in place which included instructions or preferences in relation to how the person received their medicines. Daily checks were completed to ensure the temperatures at which people’s medicines were kept were correct. Keeping medicines at inappropriate temperatures can cause their efficiency to decrease. We observed guidance for staff was in place in relation to people who required as and when medicines (PRN). This included information on the dosage and when these should be given.

Staff were knowledgeable about medicines processes and policies. We observed staff administering people’s medicines and completing medicines administration records (MARs) appropriately. The registered manager confirmed, “There have been no recent medication errors. Competency checks are done yearly unless there has been an issue, in which case it is done in response to this. I would do an observation and a theory element too to check a staff member’s competency.”