Belmont Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The management team was working towards providing a positive and open culture, so that people, relatives and staff felt listened to and included. The provider balanced recruitment challenges and other external pressures by managing ongoing recruitment drives and supporting staff development.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The service had experienced several changes to management over the last couple of years. The current manager although relatively new in post had worked as the deputy manager at the home prior to this. Staff said the manager was very supportive and a member of staff said, “Our manager listens to us and asks us for our suggestions. He is very approachable.” Staff said handovers were managed well. The provider arranged for senior management from their other homes to give support and guidance around some aspects of governance such as care reviews.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy and there was relevant information in staff areas about how to raise concerns. Staff said they would raise any issues if necessary and were confident they would be listened to and addressed.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were appropriate policies and staff completed equality, diversity and inclusion training. Staff did not report any concerns and felt they were treated fairly.

The provider did not have systems to support good governance. They did not act on the best information about risk, performance and outcomes.

Although risk had been considered, we found at times guidance was not clear, was contradictory or out of date; care was not delivered in line with people’s needs. This had not been identified by the provider. We found that some aspects of medicines management were unsafe and people had missed several doses of their medicines. Although audits were in place, they had not been effective at fully identifying or addressing concerns. We did not identify any occurrence of harm, and the manager took steps immediately to address following our feedback.

However, the manager submitted statutory notifications following incidents to relevant organisations.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Activities co-ordinators worked with the local community and invited representatives to the home on a regular basis. There were links with local schools and churches, and the service organised coffee mornings and fayres. The provider used local suppliers to support business in the area.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

There were missed opportunities to learn lessons and make improvements as the incident management processes required strengthening. Some of the audits did not identify or address concerns found during the assessment. However, the management team made sure they kept up to date with guidance provided by the department of health and other relevant organisations. They attended provider forums, regional meetings and professional networks, and held subscriptions with membership organisations so received regular updates about current and best practice.