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Inspection Summary

Overall summary & rating


Updated 18 August 2017

Belstead Villa provides accommodation, care and support for up to four adults with a learning disability, autistic spectrum conditions and associated complex needs. There were two people living in the service when we carried out an unannounced inspection on 28 and 30 June 2017.

At our last inspection 14 April 2015 we rated the service as overall good, however well led was rated as requires improvement. At this inspection we found that previous shortfalls in this area such as not having a registered manager had been addressed and effective systems and procedures had been implemented to monitor and improve the quality and safety of the service provided. These improvements contributed towards people consistently receiving safe, effective, compassionate and high quality care.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The atmosphere in the service was friendly and welcoming. People received care and support that was personalised to them and met their individual needs and wishes. Staff respected people’s privacy and dignity and interacted with them in a caring, compassionate and professional manner. They were knowledgeable about people’s choices, views and preferences. Relatives were complimentary about the care provided and the approach of staff and the registered manager.

People were safe and staff knew what actions to take to protect them from abuse. The provider had processes in place to identify and manage risk. Regular assessments had been carried out and care records were in place which reflected individual needs and preferences.

Recruitment checks on staff were carried out with sufficient numbers employed who had the knowledge and skills to meet people’s needs. Retention of staff was good and supported continuity of care.

Appropriate arrangements were in place to ensure people’s medicines were obtained, stored and administered safely. People were encouraged to attend appointments with relevant professionals to maintain their health and well-being. Where people required assistance with their dietary needs there were systems in place to provide this support safely.

People and or their representatives, where appropriate, were involved in making decisions about their care and support arrangements. As a result people received care and support which was planned and delivered to meet their specific needs. Staff listened to people and acted on what they said.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLs). Staff understood the need to obtain consent when providing care. Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLs and associated Codes of Practice

People were encouraged to maintain relationships that mattered to them such as family, community and other social links. They were supported to pursue their hobbies and to participate in activities of their choice. This protected people from the risks of social isolation and loneliness.

There was a complaints procedure in place and people knew how to voice their concerns if they were unhappy with the care they received. People’s feedback was valued and acted on. There was visible leadership within the service and a clear management structure.

Effective systems and procedures had been implemented to monitor and improve the quality and safety of the service provided. Identified shortfalls were addressed promptly which helped the service to continually improve.

Inspection areas



Updated 18 August 2017

The service was safe.

Staff knew how to keep people safe from abuse. There were systems in place to keep people safe from harm.

There were sufficient numbers of staff who had been recruited safely and who had the skills to meet people’s needs.

People received their medicines safely.



Updated 18 August 2017

The service was effective.

Staff were trained and supported to meet people’s individual needs. The Mental Capacity Act (MCA) 2005 was understood by staff and appropriately implemented.

People were supported to maintain good health and had access to appropriate services which ensured they received ongoing healthcare support.

People’s nutritional needs were assessed and they were supported to maintain a balanced diet.



Updated 18 August 2017

The service was caring.

Staff knew people who used the service well, respected their preferences and treated them with dignity and respect. People’s independence was promoted and respected.

People were listened to and their views valued when making decisions which affected them.

People’s relatives were complimentary about the effective relationships that they had with the management and the staff.



Updated 18 August 2017

The service was responsive

People’s care and support needs were regularly assessed and reviewed. Where changes to their needs and preferences were identified these were respected and acted upon.

People were able to pursue their hobbies, participate in activities of their choice and to maintain links within their local community.

Feedback including comments, concerns and complaints were investigated and responded to and used to improve the quality of the service.



Updated 18 August 2017

The service was well-led.

There was an open and transparent culture at the service. People, relatives and staff were encouraged to contribute to decisions to improve and develop the service.

Staff were encouraged and supported by the management team and were clear on their roles and responsibilities.

Effective systems and procedures had been implemented to monitor and improve the quality and safety of the service provided.