Bellsgrove 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 Good.

At our last assessment we rated this key question Requires Improvement. We also identified a breach of Regulation 17 (Good governance) At this assessment the rating has changed to Good and the service was no longer in breach of Regulation 17.

Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The registered manager told us, “I like to be visual and use our staff meetings as a platform for any discussions. If staff feel they can’t discuss it there and then I have an open-door policy. I want them to feel they are empowered and listened to. I’m here as a backup if needed and as it’s a small home I can be hands on and see what’s going on.” We observed the registered manager walking around the home and engaging with people who she appeared to know well. One friend of a person told us, “[The registered manager] is so approachable. I’ve never had any cause of concerns when visiting.” Another relative confirmed, “The management team run things very well as far as I can tell. They are communicative and very hands on and respond to all comments and suggestions we make and have a very open approach to discussion.” Staff felt supported by the management team. One staff member told us, “We can go to both the registered manager and the provider, and they are always here for us. Even when I worked nights, they would be here for us.” Another staff member said, “We are all well supported and valued by the management.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager told us, “I think it’s good within the staff meetings that they feel they can bring things up there. If there’s any issues it’s to get things sorted as soon as possible. The whistleblowing policy is on display in the office too. If there are two staff that don’t see eye to eye, I like to bring them into the office to discuss it before it escalates.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The registered manager completed detailed audits in various areas of the service, such as daily walkarounds and medicines audits. From this, the registered manager completed a monthly analysis of their findings and documented any actions that were required. For example, they identified one person needed a new cabinet in their room as the current one was not fit for purpose. This arrived on the day of our onsite assessment.

Analysis took place to determine if there were any trends to falls within the service, such as them happening at a certain time of the day which could indicate further staff were needed at that time. From this, we observed the registered manager was assured there were no themes.

However, when we first arrived at the service staff members were unable to tell us who was overseeing the shift until the registered manager and provider arrived later in the day. This meant there was not a clear management structure in place when the registered manager and provider were not available. Two staff members told us this meant they were not able to access and print certain documents that were held on the registered manager’s computer such as MAR charts and a list of people living at the service. This could lead to an error in the care people received. The registered manager informed us they would work to address this immediately after the onsite assessment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. This included using services such as advocates, chiropodists and hairdressers. One external stakeholder fed back to us, saying, “I have no issues with this home, and the registered manager is always available when I visit to answer any queries and to give me accurate update on my clients.”

External performers were booked to provide entertainment to people, and the provider regularly held summer BBQs and Christmas parties. One person told us, “There are a lots of things to do.”

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.