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Inspection Summary

Overall summary & rating


Updated 28 April 2021

About the service

Bell Lodge is a residential care home providing personal care for up to 15 people with dementia

physical disabilities and/or sensory impairments. At the time of inspection there were 11 people being supported at the service.

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

Risk to people’s safety and health were not always identified, assessed and managed appropriately. People did not have all the appropriate risk assessments in place to keep them safe. Their records did not identify how risks were managed. Repositioning charts, safety checks and food and fluid charts were not in place for people who required them.

The provider did not have effective systems and processes in place to ensure oversight of the service. The environment required improvements to keep people safe

Infection control required improvement. We saw a number of poor practices including the unsafe disposal of used personal protective equipment (PPE). Areas of the service did not have cleaning schedules in place, and we found gaps in the recorded cleaning schedules.

Medicine management required improvement. We found information missing on people’s medicine administration records. We could not be assured people received their prescribed medicines. Protocols were not consistently in place to ensure staff knew when to give a ‘as required’ medicine.

Unexplained bruising and injuries were not consistently logged or investigated to ensure they did not happen again or make improvements in peoples care and treatment.

Records were not kept up to date. We found gaps in multiple records, some records were difficult to understand, and the handwriting was not clear.

Due to COVID-19 people were not supported by staff who knew them or had all the relevant information available to understand their needs. The provider had not completed a comprehensive contingency plan in case of staff shortages and relied heavily on agency staff within the home.

People did not always receive person centred care. We were not assured that the provider had sought health care support for people in a timely manner.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was requires improvement (Published 17 October 2020) and there was a breach of regulation 17; Good Governance. The provider do not completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had not been made and the provider was still in breach of regulations.

Why we inspected

We received concerns in relation to staffing levels, safe care of people and management oversight. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only.

We reviewed the information we held about the service. However, due to the COVID-19 outbreak and people being moved out of service we did not inspect the other key questions and this impacted on gathering information for the key question caring. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bell Lodge on our website at


We are mindful of the impact of the COVID-19 pandemic on our r

Inspection areas



Updated 28 April 2021

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 28 April 2021



Updated 28 April 2021

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 28 April 2021



Updated 28 April 2021

The service was not well-led.

Details are in our well-led findings below.