Archived: Belle Vue Care Home

Belle Vue Care Home is a purpose built care home registered to provide care for up to 52 people. On the days of the inspection there were 33 people living there. The home is set over three floors, with people receiving general nursing care on the ground floor and a locked unit for people living with dementia and mental health diagnosis issues on the first floor. The lower ground floor contains service areas, such as the kitchen. People living on the ground floor had significant physical ill health and were mainly but not exclusively older people.

Following their last comprehensive inspection on 18 July 2016, the home was rated as Inadequate and placed in 'special measures' due to concerns we identified. These included concerns from the preceding inspection of June 2015 which had not been addressed.

In 2016 we identified concerns in relation to people's safety, staffing levels, management and governance of the home, and lack of caring and respect for people's dignity. Following that inspection, we issued three warning notices in relation to Regulation 12 (Safe care and treatment), Regulation 10 (Dignity and Respect) and 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We met with the provider when they shared the actions they were taking to address the issues identified.

We found some progress had been made by the home when we carried out a focused inspection in December 2016.

We carried out this comprehensive inspection in March 2017. We found not all improvements seen during the focused inspection had been sustained. The required improvements identified at the comprehensive inspection in July 2016 had not been completed. We identified concerns in relation to people’s safety, safeguarding, person centred care, dignity and respect, staffing and good governance.

The home did not have a registered manager, although this person’s name will show on this report as they have not deregistered. There was an interim manager in post at the time of our inspection who had begun the process of applying to the Care Quality Commission for registration. 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.

During this inspection we found that the systems in place to reduce risks associated with people's care and support were not always effective and this exposed people to the risk of harm. In addition to this people were not protected from risks associated with the environment. Some areas of the home needed additional cleaning or maintenance, and there was a significant odour problem, particularly on the first floor dementia unit.

People did not always receive appropriate care and support as staff were not deployed in a way that supported people to have their needs met in a timely way. People were exposed to risk of harm. We observed occasions where people had to wait unacceptable amounts of time for support.

People's right to privacy was not respected and they were not treated with dignity. Staff did not routinely supervise the whereabouts of people. This meant people walked into other people’s rooms uninvited. Some staff were kind and caring in their approach, however other staff were focused on tasks and had limited interaction with people who used the service. Supervision and observations of staff had not identified, or had not addressed these issues in a way that ensured people had positive experiences.

Staff interactions were not always supportive to people. Staff did not support people to make decisions and choices about their care. For example, staff asked people for their meal choice at lunchtime but they did not clearly explain what was on offer and encourage people to make a choice for themselves.

People were disengaged and under stimulated. They were not provided with appropriate person centred stimulation and some people were at risk of social isolation. People spent long periods of time on their own either in the reception lounge area, in their rooms or looking out of the window. We did not see any activities taking place during our inspection.

People were not always protected from risks associated with their care. Risk assessments were not always in place or written in sufficient detail to support people to receive safe care and support, or to manage identified risks. People did not always have sufficient detail in their care plans to provide guidance and direction to staff about how to meet their needs or to care for them in a personalised manner.

People waited extended periods of time for their meals, and some people had been left with their meals but were not offered encouragement or support to eat. Some people’s food and fluid intake charts were not being accurately completed which could lead to confusion about how much they were eating and drinking.

People were not always being protected from the risks associated with medicines. During the inspection we observed unsafe practice. Staff were not always recording when topical creams were applied. Other aspects of medicines management were safe. We saw medicines were stored securely and records were maintained.

There was a lack of effective governance which put people at risk of receiving poor care. Quality assurance and audits systems were ineffective. Whilst systems were in place to assess, monitor and improve the quality of service for people, these had not identified the shortfalls found during this inspection and had not been effective in ensuring the home was compliant with the regulations. In addition to this, timely action had not been taken in response to known issues.

People and their relatives told us the quality, variety and choice of food had improved in recent months. Since the last inspection the home had employed a new chef who was passionate about providing people with nutritional, high quality restaurant standard food. However, we did not find the way that meals were served helped ensure people had a positive experience. The dining rooms were noisy, and people were not always supported well by staff to eat their meals.

People were supported by staff who had a good understanding of how to keep them safe, identify signs of abuse and report these appropriately. We found staff were recruited safely. Suitable checks were made to ensure people recruited were of good character and had appropriate experience and qualifications.

Improvements had been made to staff training and supervision. The registered provider had an induction and training programme in place that included training specifically to meet the needs of people living at the home.

We found the home was taking appropriate actions to protect people's rights and work within the principles of the Mental Capacity Act 2005 (MCA). Staff were aware of people's right to refuse support and asked people for their consent before they assisted them.

The provider had a written complaints procedure. Information about how to complain was provided to people and their relatives when they moved into the home and was displayed on the wall of both units. Relatives told us they knew how to make complaints.

During our inspection, we acknowledged the manager and interim clinical lead were working hard to make improvements. The manager had identified several areas of concern which they were trying to address. The manager was working hard to maintain a stable staff team and staff felt well supported by the management.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’.

The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

We are considering our actions in line with CQC's enforcement policy. We will publish a further report that details what action we have taken at a future date . Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Belle Vue Care Home is a purpose built care home registered to provide care for up to 52 people. On the day of the inspection there were 38 people living there. The home is set over three floors, with people receiving general nursing care on the ground floor and a locked unit for people living with dementia and mental ill health on the first floor. The lower ground floor contains service areas, such as the kitchen. People living on the ground floor had significant physical ill health and were mainly but not exclusively older people.

Belle Vue Care Home was last inspected on 18 July 2016. The home was rated as Inadequate and placed in ‘special measures’ due to concerns we identified. These included concerns from the preceding inspection of June 2015 which had not been addressed. Many of these issues were related substantially to the first floor dementia care unit. We identified concerns over people’s safety including unsafe practice with medicines administration, safety of the premises, risk assessments, staffing levels, management and governance of the home, and lack of caring and respect for people’s dignity. Following the inspection we issued the registered manager and provider with three warning notices in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment), Regulation 10 (Dignity and Respect) and 17 (Good Governance). We later met with the provider and management team to review progress being made. The management team have sent us a weekly progress report and action plan. The local Authority business and quality improvement team have been involved with supporting the service make improvements.

This inspection was a focussed inspection carried out to ensure the provider and management team had taken sufficient action to meet the warning notice issued in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment). We will look at the actions taken to meet the other warning notices at the next inspection. The ratings from the comprehensive inspection of 18 July 2016 have not been changed as a result of this inspection, but will be reviewed at a full comprehensive inspection carried out to review overall progress being made. This will be undertaken within six months of the service going into ‘special measures’.

We found that improvements had been made, and although some areas of progress were still needed, people’s safety had improved. People and their relatives told us they felt safe at the home, and that the home had improved in recent weeks and months.

The home had a registered manager, although they were not working at the home at the time of the 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. The service was under direct oversight of a management team from Four Seasons Healthcare (England) Limited, with an interim manager in post providing day to day cover.

People received safe care because risks to their health and well-being were regularly assessed, and risks reduced wherever possible. We saw people had received updated risk assessments in relation to pressure relief, falls, moving and positioning and nutrition. Actions had been taken to reduce risks, for example by referral to specialist agencies to provide advice on swallowing or pressure ulcer management. We identified some people were living with long term health conditions that were subject to a potential sudden deterioration. Some people did not have protocols for staff to advise them on actions to take or how to monitor the person in the case of a sudden deterioration in their condition. The interim manager agreed to ensure these were written within 48 hours of the inspection.

People befitted from living in an environment that was regularly assessed and actions taken to minimise risks. This included water temperature regulation, maintenance of equipment and window opening restriction. At the inspection we saw changes were being made to the fire management systems, including to fire doors. Following the inspection we contacted the local fire and rescue service for their specialist advice on the work being undertaken.

Learning took place to reduce the risk of re-occurrences of incidents and accidents, and systems to do this were being made more robust following a recent audit. Following the inspection of July 2016 where we had identified concerns over people’s safety and vulnerability the service had taken action. Some people using the service who had presented risks to themselves or others were moved to other services more suited to their needs and some very frail people were moved to the ground floor general nursing care area. People’s family members told this had impacted significantly on people’s well-being, and they were no longer showing signs of anxiety. The dementia care floor was much calmer and more settled. People were experiencing more organised activity as a way of preventing the risks of social isolation and frustration, which had helped with providing the calmer atmosphere. People told us the staff were happier.

People received their medicines safely and as they had been prescribed. One incident where this may not have happened was under investigation, as it was not clear whether this was a recording or practice issue. Nursing staff were regularly assessed to ensure they had maintained their competence to give people medicines safely, including through medical devices.

Belle Vue Care Home was last inspected on 10 June 2015. The home was rated as ‘requires improvement’ across all key questions at that time. Since the last inspection there had been some improvements at the home, such as the new corporate care planning systems and improvements to the staff recruitment files. However, we identified a number of concerns and breaches of legislation on this inspection in July 2016, many of which had also been issues at the last inspection which had not been resolved. Many of the issues were related substantially to the first floor dementia care unit. At the start of the inspection the registered manager had told us they were confident that the issues raised at the last inspection had been resolved.

Belle Vue care Home is a purpose built care home registered to provide care for up to 52 people. The home is set over three floors, with people receiving general nursing care on the ground floor and a locked dementia and mental ill health unit on the first floor. The lower ground floor contains service areas, such as the kitchen. People living on the ground floor had significant physical ill health and were mainly older people.

The home has a registered manager. 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.

We identified some concerns around people’s safety. People were not being protected from the risks associated with medicines. Nursing staff were not following safe practices when giving people their medicines, although this was addressed at the time of the inspection.

We found the environment was not always safe for people. Some areas of the home needed additional cleaning or maintenance, and there was a significant odour problem on the first floor dementia unit. The dementia unit had not been adapted to reflect best practice in dementia care. For example, information was not always provided to help people maintain their independence or orientate themselves to their environment. However the provider was about to deliver a dementia training package to all staff to improve the outcomes for people in this area. Work was also due to take place to make changes to the environment to make this more suitable for people’s needs. Staff who had been involved in this already were enthusiastic about it.

Risk assessments were not always in place or in sufficient detail to help keep people and others safe from risks associated with their care. We have made a recommendation in relation to the recording and monitoring of pressure ulcers in line with good practice. This would ensure that any progression or deterioration of the wounds was clearly and objectively recorded for example with photographs. Pre-admission assessments had not always been undertaken thoroughly and incidents had not always been properly assessed so had not always been escalated appropriately. This had meant that people had been exposed to risks from other people in the unit. This had been resolved at the time of the inspection.

There were not always enough staff on duty at all times to ensure people received the care, support and observation that they needed. Staff competencies or practice were not always being assessed appropriately. Although staff were receiving training it was not always clear that this was improving people’s care or was being put into practice. Staff recruitment practices were safe and had been followed in the files we saw.

People and their relatives gave us mixed information about the meals being served. Some people enjoyed their meals. However we heard from relatives and staff those meals sometimes did not meet people’s needs, in particular where there were specific dietary textures required. Meals served to people were not always suitable or varied. People were not always given a choice, and we did not see that people were given additional fluids, even though it was a hot day.

People’s care plans were not always being followed. People’s dignity was not always supported and staff did not always treat people with respect. For example, some staff communication did not support people’s wellbeing, and people’s personal standards of dress and self-care were not always being respected. Staff did not always respect people’s privacy, and the layout of the building meant it was difficult for people’s private space to be respected. Staff interactions were not always supportive to people. However we also saw some good practice, with staff interpreting people’s behaviours and offering them comfort when apparently in pain.

A new activities organiser had been appointed and was getting to know people and their wishes regarding activity before commencing a new programme of activity. However we saw little evidence that people’s wishes regarding activity or interests had been respected.

People’s rights regarding capacity and consent were being respected and staff had a good understanding of issues in practice. Applications had been made for deprivation of Liberty safeguards where needed. People had access to community healthcare services to meet their needs, and community staff told us that communication with the home was good.

There was not a positive culture at the home, and a tolerance of poor practice. Leadership was poor and management had not been effective at identifying concerns or addressing them. Some organisational policies and procedures in place to keep people safe and promote high quality care were not being followed in practice. For example staff had received training in safeguarding people, and told us they understood how to report any concerns about their welfare. However we saw an instance where staff subjected a person to degrading treatment. Improvements identified as needing to be made following the last inspection had not altered some of the practices we saw.

Records were not all well maintained. Some entries were not legible and some policies and procedures were not reflective of current practice, for example the complaints procedure.

We identified a number of breaches of regulations during this inspection. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We saw there were sufficient care workers on duty to support people at their own pace. The care workers that we saw working with people were kindly and respectful. We spoke with a person who received care. They told us that the nurses and care workers supported them well and said 'I have no complaints. They do their best for me and they can't do any more than that'.

We spoke with two care workers. They told us about the work they carried out at the home. Both were clearly passionate about the work they did. One told us 'I really enjoy my job here. I like the people and find it really rewarding'. Another told us they worked well as a team and covered for absences as a team rather than use agency staff. We did not identify any concerns over the relationship between staff and the home's management.

We saw care workers were well organised. Staffing levels were flexible to meet the challenges of the two units.

People we spoke with said they felt they had their care needs well met, agreed to the care they received and were able to make choices as part of their daily lives. One person said 'It's all good. I am well looked after.' A relative said 'They are so good here. They always call the doctor and me when X is unwell; they know him really well. The care could not be better.' We saw that people had their care needs met and had access to specialist health services as required.

We saw that the design, layout and security of the premises safely met the needs of everyone receiving care and treatment including those with disabilities. Equipment had been provided as required and systems were in place to maintain this.

People said they 'loved all the staff' and felt safe living in the home. People with dementia appeared relaxed in the company of staff. Staff knew what to do if they suspected abuse. People we spoke with and staff thought there were enough staff on duty.

People and their relatives knew how to make a complaint. We found learning had taken place from complaints and had been resolved to the satisfaction of people and their families.

We found that people's personal records, safety records and staff records were well managed, accurate and fit for purpose.

We found that complaints were not always managed according to the homes policy meaning that there was no clear evidence to show that issues had been clearly investigated or acted upon.

Records showed that emergencies and any serious injuries at the home were managed well and relevant organisations notified accordingly. We saw that referral to GP's was good. However, advice from other health care professionals and health care monitoring, at times, only took place following prompting.

Weight management at the home had not always been managed well. Calculations of a person's Body Mass Index (a measure of body fat based on a persons height and weight), and nutritional assessment were not always accurately recorded. The area manager had introduced changes to prevent this occurring.

We saw that staff were not proactive when some equipment failed in the home. For example faulty scales had not been replaced for three months. This meant that people who had had been losing weight had not been weighed for three months. We found the scales were faulty on the day of our visit.

At a previous inspection we found foot plates were not always correctly fitted to wheel chairs. However, at this inspection and two inspections earlier this year we found improvements had been made.