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Belvedere Lodge Requires improvement

We are carrying out a review of quality at Belvedere Lodge. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 1 February 2019

This inspection took place on 18 December 2018 and was unannounced. Belvedere Lodge is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual arrangement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to accommodate up to 20 people and at the time of the inspection there were 15 people residing in the home. The home is a converted Victorian property with facilities over four floors. There is a stair lift in situ which means there is access to all bedrooms apart from the two bedrooms in the basement. A number of bedrooms had en-suite facilities.

When we inspected the service in November 2016 there were no breaches of legal requirements and we gave the service a quality rating of Good.

There was a registered manager in post (registered in July 2018). There had been a change in registered manager since the last inspection. 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.

Improvements were required with the management of medicines to ensure people were completely safe. There had been a significant number of medicine errors (no harm to people), where the care staff were either not signing to say they had administered medicines, were not checking records correctly or were administering medicines at the wrong time of day. Regular audits were taking place and staff were being spoken with but this was not improving practice.

Improvements were also required with the care records for each person. Each person had a care plan but this was not person centred. The information contained in the care plans was computer generated and not always relevant to the person’s specific care and support needs. The recordings in people’s daily notes was of a poor quality and did not reflect the care and support they received.

Staff received safeguarding vulnerable adult training as part of the provider’s mandatory training plan. Staff would report any concerns about a person’s welfare to the registered manager, the deputy, ‘head office’ or the Care Quality Commission. Safe recruitment procedures were in place to ensure only suitable staff were employed. The appropriate steps were in place to protect people from being harmed.

Any risks to people’s health and welfare were assessed and people’s care plans detailed how these risks were managed to reduce or eliminate the risk. The premises were well maintained with regular maintenance checks being completed. Checks were also made of the fire safety systems, the hot and cold-water temperatures and any equipment to make sure it was safe for staff and people to use.

The number of staff on duty for each shift was based on the number of people in residence at any given time. Consideration was also given to the dependency level of each person and any social activities that were taking place in, or outside of the home. Staffing levels were adjusted as and when necessary. Staffing levels were appropriate at the time of the inspection.

People received an effective service. The staff team received training to ensure they had the necessary skills. New staff had an induction training programme to complete. Staff were well supported by the registered manager and the deputy although improvements were necessary to ensure improvements were made in work performance.

People’s capacity to make decisions was part of the care planning process. People were always asked to consent before receiving care. They were encouraged to make their own choices about aspects of their daily life. We found the service to be meeting the requirements of the Mental

Inspection areas


Requires improvement

Updated 1 February 2019

The service required improvement to be fully safe.

People�s medicines were not managed safely because the staff were not following safe work practices.

Staff received training in safeguarding issues and were aware of what to do if concerns were raised. Recruitment procedures were robust and ensured only suitable staff were employed.

Any risks to people�s health and welfare were well managed and the premises were well maintained and safe.

There were sufficient staff on duty at all times to ensure people�s needs were met and they were safe.



Updated 1 February 2019

The service remains Good.


Requires improvement

Updated 1 February 2019

The service was on the whole caring but the approach of some staff required improvement.

People were not always treated in a kind, loving and dignified manner.


Requires improvement

Updated 1 February 2019

The service requires improvement to ensure it remains responsive to people�s care and support needs.

People�s care records did not accurately reflect their care and support needs. The risk of staff not responding appropriately was increased.

There was a meaningful programme of activity arranged for people.

People would be listened to if they had any complaints. The service would aim to continue to look after people when they needed palliative or end of life care.


Requires improvement

Updated 1 February 2019

The service requires improvement to be well led.

There was a good leadership and management in place however the implementation of a change in culture within the staff team was work in progress. The service needed to establish a staff team that works together for the benefit of people.

The programme of quality checks and audits were identifying where improvements were required but need to be extended to ensure any breaches in regulations are identified.