Belvoir Care Home Limited

Updated 25 January 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by an inspector, a medicines inspector and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Belvoir Care Home Limited is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Belvoir Care Home Limited is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 9 January 2024 and ended on 11 January 2024. We visited the location on 9 January 2024.

What we did before the inspection

We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, nominated individual and 2 staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We spoke with 5 people receiving care and a relative who was visiting the location at the time of the inspection. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke to a further 4 relatives and received feedback from 5 staff after the onsite inspection.

We reviewed 3 people's care records and their records for the administration of medicines. We reviewed records and audits relating to staff recruitment, and the management of the service, including infection control, risk assessments and management audits.

We asked the registered manager to send us documents after the onsite inspection. These were provided in a timely manner and this evidence was included as part of our inspection.

Updated 25 January 2024

About the service

Belvoir Care Home Limited is a care home providing personal care to older people and people living with dementia. The service accommodates 24 people in one adapted building, over 2 floors. The service has 19 bedrooms, of which 5 are double rooms for families. At the time of the inspection 19 people were using the service and no bedrooms were being used for double occupancy.

People’s experience of using this service and what we found

The building was designed to meet the needs of the people receiving care. However, observations and feedback received highlighted the need for some renovations and upgrades. We made recommendations about further enhancing dementia-friendly environments.

Staff were trained to recognise potential risks and signs of abuse. Risks to people's safety and wellbeing were assessed and reviewed by the registered manager. Staffing levels were safe. The provider managed medicines safely. Staff used personal protective equipment (PPE) appropriately when supporting people.

People's needs were assessed and reviewed regularly. Healthy lifestyles were promoted, and systems were in place to make sure people's health needs were met. Menu planning met people's dietary needs and considered individual and cultural preferences. Staff had the skills and knowledge to deliver care effectively.

Staff knew how to communicate effectively with residents and were trained to meet people's needs at the end of their lives. Activities were meaningful and supported social inclusion. Relatives were encouraged to visit and had access to care plans where appropriate.

People told us staff were polite and always asked before providing care and support. Care plans were personalised and showed the care and support people wanted and needed. People and relatives knew how to raise concerns and were confident these would be dealt with appropriately.

The provider ensured systems were in place to monitor the running of the service. Staff worked well in partnership with other agencies to deliver effective care. The registered manager audited care and support records, to assure themselves of quality. Lessons were learned when concerns were raised, and these outcomes were communicated to staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 19 October 2017).

Why we inspected

We undertook this inspection as part of a random selection of services rated good, and due to the length of time since the service was last inspected.

Recommendations

We have made a recommendation about the design and decoration of the service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.