Background to this inspection
Updated
12 January 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 Care Act 2014.
Inspection team
The inspection was carried out by one inspector.
Service and service type
The Belfry is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. 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.
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 and sought feedback from the local authority. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with one person who used the service and two relatives about the care provided and we used observations to gather evidence of people’s experience of care. We spoke with five members of staff including the registered manager and care workers.
We reviewed a range of records. This included three people’s care and medicines records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance documentation. We spoke with one professional who has regular contact with the service.
Updated
12 January 2022
About the service
The Belfry is a residential care home providing personal care to 11 people aged 65 and over at the time of the inspection. The service can support up to 12 people.
People’s experience of using this service and what we found
The provider did not have robust systems in place to assess and monitor risks to people’s safety and welfare. People’s care plans and risk assessments were not always up to date and did not provide staff with clear guidance about how to support people safely in a number of key areas including their mobility, eating and drinking and personal care. People’s medicines were not always safely managed, and the provider’s medicines audits had failed to highlight the errors found on inspection.
We could not be assured the service had adequate staffing levels in place to provide people with personalised care which reflected their individual needs and preferences. Staff had not received a comprehensive induction and training was not always completed or renewed in line with best practice. The provider had not always completed the relevant recruitment checks in line with best practice. We have made a recommendation about the provider’s recruitment processes. Despite these concerns, people were generally supported by a consistent staff team and relatives spoke positively about the staff employed.
People’s care was not always personalised and their involvement in their care planning was not evident from their care records. People’s care centred on their physical health needs and people were not always supported to take part in meaningful social interactions or leisure activities of their choice. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
The provider had safe infection prevention and control processes in place and the service was environmentally clean and homely. People were supported to stay in regular contact with relatives and the provider ensured visitors were welcomed into the service.
The provider encouraged people, relatives and staff to give feedback on the care provided and responded to concerns and complaints appropriately. A safeguarding policy was in place for staff to follow if they had any concerns people were at risk of abuse.
People’s relatives spoke positively about the culture and management of the service and the provider had built positive working relationships with other health professionals in order to support people’s health needs and improve their care.
The provider responded promptly to the feedback we gave during our inspection, putting measures in place to address concerns and make improvements.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 17 April 2018)
Why we inspected
We received concerns in relation to the safe management of medicines, the management of risks to people’s health and safety, safeguarding people from the risk of harm and staff training and knowledge. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive and well-led only.
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.
We reviewed the information we held about the service. No areas of concern were identified in the other key question. We therefore did not inspect this. Ratings from the previous comprehensive inspection for this key question were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvement. Please see the safe, effective, responsive and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Belfry on our website at www.cqc.org.uk.
Enforcement
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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to people’s safety, staffing and the oversight 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.