Belvedere House 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. This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive 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 management team and provider ensured thorough investigations of accidents and incidents took place to determine the actions that may be required to reduce the risk of reoccurrence. Learning from events had been cascaded through the staff team and staff confirmed communication was good and they were promptly informed of any changes in people’s care. One staff member told us, “The [Management team] go through lessons learned at staff meetings or before if there is something urgent, we need to change.” The registered manager and provider had systems in place to ensure accidents and incidents were regularly analysed for to identify any emerging themes or patterns to improve the care provided.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People’s needs were thoroughly assessed prior to them using the service to ensure their needs could be safely met. Key information was sought from the person, their relatives and any external professionals involved in the person’s care to enable a positive transition into the service. Arrangements were in place to ensure people’s health needs were monitored and met; staff worked with GP’s and community nurses to seek information and advice which was detailed in people’s care plans.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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 provider shared concerns quickly and appropriately. Staff had received training in safeguarding. We found effective systems in place to ensure accidents and incidents were investigated and analysed. The registered manager had taken appropriate action when safeguarding incidents had occurred. This included carrying out their duty in accordance with the duty of candour and reporting to external agencies such as the local safeguarding team and CQC. The provider also analysed and monitored events that occurred to identify any themes and trends and to ensure their policies and procedures were followed. We found safeguarding information was on display in the service which told people, staff and visitors of what they could do if they had a safeguarding concern. People and their relatives told us the service was safe. One person told us, “It’s a good home, I like it here, I’m happy, staff are good to me.” Relatives also provided positive feedback such as “I feel it is safe for [person]”, “I have no safety concerns” and, “Staff display incredible patience, [Person] often tells me they feel really loved.”

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. Risks which affected people's daily lives, were documented and known by staff. The management team monitored and regularly assessed these risks and took appropriate actions to ensure people received care in a safe and consistent way. We observed staff to demonstrate a good understanding of how to support people positively with their known risks, for example people staff were fully aware of who needed support with eating and drinking and who required modifications to their food and drink to reduce their risk of choking. We also observed staff positively support people living with dementia and staff told us of the individual strategies they used to reassure people which was in line with their care plans. We found technology in place to support people who had consented to use of sensors in their environment, this maximised people’s safety by alerting staff to their movements.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had systems in place to ensure the environment was regularly checked for any potential hazards. We found all health and safety compliance certificates in place; however, emergency lighting and fire extinguisher checks had not always been carried out with the required frequencies throughout the year. The registered manager and provider had recognised this and had put it right. We found the service to be well maintained and the furnishings and lay out of building met people’s needs. For example, chairs and handrails were available throughout the corridors for people to use. The service was spacious and well maintained, there was many areas for people to use throughout the day including a cinema room, communal lounges and outside space that could be accessed from each floor.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff were recruited safely. The provider followed safe recruitment processes to ensure people were suitable for their roles. This included undertaking appropriate checks with the Disclosure and Barring Service (DBS) and obtaining suitable references. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. People were provided with opportunities to be involved in the provider’s recruitment process; the provider had worked with people to develop questions they would like prospective staff to be asked. We observed staffing levels throughout our inspection to meet people’s needs. Staff were attentive and call bells were answered promptly which ensured people received the care they required in a timely manner.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had systems and processes in place to ensure infection, prevention and control measures were regularly audited. The service had an infection, prevention and control champions in place who had received additional training and were a point of contact in the service for advice and how the processes in place were managed. We observed staff to follow the infection, prevention and control measures in place and staff demonstrated a good understanding of their role in reducing the transmission of infection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were safely managed; stock levels corresponded with the records in place and audits of medicine administration records were conducted regularly by the management team and provider. Staff had received training in the administration of medicines and had regular checks of their competency. People confirmed they received their medicines when they needed them. One person told us, “Staff are very good, when I am in pain, they bring me pain relief.”