Belong Chester

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. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, and the way medicines were managed.

This service scored 56 (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 provider had established governance systems in place which were being further developed and embedded to strengthen oversight and incident management. Incidents were investigated and analysed to identify lessons learned and trends. For example, falls analysis completed for a person who was at risk of falls highlighted a reduction in falls following implementation of new equipment.

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.

The provider offered ‘experience days’, which enabled people to visit the service and become familiar with it before moving in. This supported people to transition smoothly into the service. The manager had recently identified areas where relationships with healthcare partners could be improved and introduced new processes, in collaboration with partners, to support this.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, the provider had not always shared concerns quickly and appropriately. We found there was a delay in reporting one safeguarding concern to CQC.

At the time of the assessment, the provider was already working closely with the local authority to review their safeguarding referrals. Reviews of recent safeguarding incidents had already identified areas for improvement including inconsistencies in documentation and following escalation processes.

The manager acknowledged these lessons learned and implemented new processes to improve the management of safeguarding concerns. This included holding coaching sessions for staff and meeting with local GP’s and district nurses to improve communication and relationships.

The provider worked with people to understand and manage risks. However, staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

For example, there had been incidents relating to poor manual handling. Whilst we were on site, we observed an incident of poor moving and handling practice. This was reported to the manager who took appropriate action by raising a safeguarding referral, fully investigating the incident, and completing observations and reflective discussions with the staff members involved.

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 environment risk assessments in place to identify potential hazards around the home, which assured us risks to people had been reduced. Staff completed regular safety checks throughout the home, and safety certificates, such as gas and electrical certificates, were in place and up to date.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Feedback from most staff was they felt there were not enough staff and they were unable to keep up with the responsibilities of cleaning, cooking and laundry, alongside caring for people. One staff member told us, “There is not enough staff. We also have to do some cleaning and laundry, and cooking also,” while another commented, “We can’t do it all. We don’t have enough time to sit down and talk to the residents.”

Family members shared mixed feedback about staffing levels. Comments included, “The staff don’t seem to have time to spend time to be just with people. They seem to always be very, very busy,” “I tend to know the staff. They seem to be well covered with staff,” and “The staffing levels are changeable, yesterday there were 4 staff there and other times there was one person there.” This feedback was shared with the management team, who had an ongoing plan to continue reviewing staffing levels and staff responsibilities. The manager completed a full review of staffing and was in the process of developing a new rota and adjusting staffing levels and shift patterns where required.

Records relating to staff supervisions showed not all staff had received supervision in line with the provider’s policies. There were some staff who had not received any supervisions in 2025. This was fed back to the manager, and supervisions were scheduled to take place before the end of the year for these staff members.

The provider had a dedicated on-site trainer who delivered a thorough induction and training programme. Staff gave positive feedback about the training they received. However, we identified areas where training could be improved to further enhance the care delivered to people. This included training in oral health and some specialist health needs. The manager was very responsive to this feedback and arranged for additional specific training to be held.

The provider did not always assess or manage the risk of infection.

On the first day of our site visit, we observed general uncleanliness across the households, which included dirty bed sheets, kitchens, mattresses, pillows and equipment. Staff we spoke with were unclear about their responsibilities in relation to some infection prevention and control (IPC) procedures. These concerns were shared with the management team. On the second day of our site visit, we observed a noticeable improvement, including improved cleanliness and odour control across the households, with domestic staff more visible and active throughout the day. The provider had taken action to clarify staff responsibilities in relation to IPC.

In addition, people did not always receive personal and oral hygiene care in line with best practice or their recorded preferences. Records we reviewed showed significant gaps for some people. Our observations identified dry and dirty toothbrushes in some people’s bedrooms indicating a lack of oral care being carried out. Poor oral and personal hygiene increases the risk of infection. The manager took immediate action in response to this feedback by arranging additional oral care training and increasing spot checks.

Staff treated people with kindness, dignity, and respect, and the administration of medicines was recorded in people’s electronic medicines administration records (eMARs). However, staff did not always follow the prescriber's instructions when administering medicines. For example, a medicine was given with food instead of before, which may have reduced how well the medicine worked.A thickener was observed stored in an unlocked cupboard, which meant it was not being kept securely.

Fridge temperature monitoring was recorded daily; however, staff did not act when readings exceeded the recommended maximum temperature. On inspection, we observed a person’s medicine was being stored in a room that had previously stopped storing medicines due to high temperatures. The temperature in this room was not being monitored while the medicine was stored there. As a result, assurance could not be provided the medicine was safe to use.

Controlled drugs (which are medicines requiring more control due to their potential for abuse) were stored safely and securely, with access restricted to authorised staff. We found a CD balance check had been completed without a second signature, indicating the required double-signature process was not followed. The provider therefore could not demonstrate that safeguards to prevent error or misuse were being actioned.

Dates of opening for medicines with reduced shelf life after opening were missing. This was observed with liquid medicines and insulin that had been removed from the fridge. This meant there was a risk that medicines could be used after they were no longer safe or effective, thereby reducing their effectiveness.

Time-critical medicines for Parkinson's disease were not always given at the right time to ensure they were effective for people. We saw examples of people who had not received their dose hours after the required time. This would have affected this individual’s quality of life.

When people were prescribed medicines to be given ‘when required’, person-centred care plans were not in place to support people in having their medicines in a clear and consistent way.This lack of detail increased the risk of inconsistent care and made it difficult for staff to make informed decisions.

Care plans were not person-centred and did not contain sufficient information to allow staff to manage people with complex medical conditions such as Parkinson's disease or epilepsy. The lack of condition-specific care plans meant staff lacked the necessary information to provide appropriate, consistent, and safe care.

Some people were given their medicines covertly (disguised in food or drink). This was clearly documented in their eMAR. Best Interest meetings had been carried out, and the appropriate people were present. Staff had access to appropriate pharmaceutical advice to ensure these medicines, given covertly, were administered safely.

Following the inspection, the management took the medicine issues we identified during the inspection seriously and took action to improve the safety of medicines.