Archived: Belvedere Manor

Belvedere Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is purpose built and accommodates 84 people on three floors known as Village, Woodlands and Garden suite. Woodlands suite specialises in providing care for people living with dementia. At the time of the inspection, there were 71 people accommodated in the home.

The service was managed by 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.

At the last inspection carried out on 6, 7, 8 and 13 November 2017, we asked the provider to make improvements to improve the assessment of staffing levels, the management of risks, the management of medicines and the implementation of the Mental Capacity Act. Following the inspection, the provider sent us an action plan and told us they would make the necessary improvements by April 2018.

During this inspection, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 and one breach of the Care Quality Commission (Registration) Regulations 2009. We found continuing shortfalls in the management of medicines, the way risks to people’s health, safety and welfare were managed and the application of the Mental Capacity Act. In addition, we identified further shortfalls in the staff recruitment process and the governance arrangements as well as a failure to submit some statutory notifications.

We are considering what action we will take in relation to these breaches. Full information about the CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

At the last inspection, the service was rated as overall ‘requires improvement’, at this inspection the rating had deteriorated to overall ‘inadequate’.

Safeguarding adults’ procedures were in place and staff spoken with understood how to safeguard people from abuse. However, staff failed to recognise a serious occurrence was a safeguarding incident and delayed completing an incident report. Whilst there was evidence to indicate the circumstances of the incident had been investigated there was no evidence seen to confirm the incident had been reported under safeguarding adults’ procedures.

We saw people’s care files contained individual risk assessments, however, not all risks had been assessed and recorded and consistent action had not always been taken to mitigate risks.

We found serious shortfalls in the recruitment of new staff. Prior to the inspection, we asked for a list of all new members of staff along with details of a specific employment check. The list was confirmed as accurate and correct by the area manager and the registered manager. During the inspection, we found appropriate checks had not been carried out for a member of staff who had been omitted from the list. Whilst the registered manager explained this was an oversight, it meant the information submitted was inaccurate and misleading.

We found dependency profiles had been completed for all people living in the home to help determine the level of staffing. However, people, staff and relatives continued to express concern about the number of staff on duty.

We found there were continued shortfalls in the management of medicines. This included gaps in record keeping and a lack of guidance for staff.

Whilst staff told us they had completed appropriate training, the provider was using four different systems to manage and monitor staff training. This meant we were not able to assess the training completed by staff during the inspection. The registered manager offered to send us an up to date training matrix, however, this was not received. Not all staff had completed induction training when they commenced work in the home and not all staff had received the number of one to one supervisions advised by the provider’s policies and procedures.

The provider was not working within the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) to help ensure people's rights were protected.

Whilst people had access to healthcare services, we found staff had not responded in a timely way to GP advice in respect to one person’s health.

People and relatives told us the staff were caring and kind. However, there was limited evidence to demonstrate people had been involved in the care planning process. This meant people were not given the opportunity to have direct input into the planning of their care.

Each person had an individual care plan, however, we noted some care plans contained conflicting information, which could impact on the delivery of care.

There was a complaints procedure in place and we saw evidence complaints had been investigated and responded to. However, not all complaints had been recorded in a central log, which meant concerns were not considered as whole in order to identify any patterns or trends.

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.

Belvedere Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is purpose built and accommodates 84 people on three floors known as Village, Woodlands and Garden suite. Woodlands suite specialises in providing care for people living with dementia. At the time of the inspection, there were 75 people accommodated in the home.

The service was managed by 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.

At the last inspection on 18 and 19 November 2015, the home was meeting all legal requirements. At this inspection, we found there were four breaches of the regulations and we therefore asked the provider to take action to improve the assessment of staffing levels, the management of risks, the management of medicines and the need for consent. You can see what action we told the provider to take at the back of the full version of the report. We also made recommendations about the environment in order to support people living with dementia and people’s involvement in the care planning process.

This is the first time the service has been rated Requires Improvement.

People told us they felt safe and secure in the home. Safeguarding adults’ procedures were in place and staff understood how to safeguard people from abuse. However, people, relatives and staff spoken with expressed concerns about the level of staffing in the home. We found there were no assessment tools used to determine the appropriate level of staffing. Appropriate recruitment procedures were followed to ensure prospective staff were suitable to work in the home.

Individual risks were assessed and recorded, however, we found people had experienced falls in the last month where the room sensors had been switched off. This meant the provider had failed to take action to mitigate the risks to people’s health and safety. There was no analysis carried out of the accidents and incidents in order to identify any patterns or trends. We also found people’s medicines were not always managed safely.

There was limited evidence to demonstrate the service was working within the principles of the Mental Capacity Act. Whilst assessments had been carried out to assess people’s mental capacity, there was no information added to the assessments to support how decisions had been reached. We also found conflicting information about people’s ability to provide consent.

We observed some people living on Woodlands suite found it difficult to find their bedrooms. This was because there were few adaptations to the environment to help people orientate themselves.

People had mixed views about the food provided. Whilst there was ongoing work to improve people’s dining experiences, we found people were not always fully supported during meal times.

The registered manager had developed a training matrix and staff were provided with appropriate training. Staff also had regular supervision with their line manager.

People told us that staff often had limited time to spend with them due to the level of staffing. We noted staff had opened all the windows in the dining room on Garden suite. This lowered the temperature of the suite and had implications for people living in this area of the home for the rest of the day.

Whilst people had individual care plans, we found limited evidence to demonstrate people had been involved in the care planning process. This is important to ensure people’s wishes and preferences are fully recorded. We also found some staff had not read the care plans, which meant there was a risk of inconsistent care.

All people, relatives and staff were very complimentary about the activities provided in the home. A broad range of activities was arranged daily both inside and outside the home in line with people’s personal preferences. All people were provided with a weekly activity planner. We observed activities during the inspection and noted there was a vibrant cheerful atmosphere.

People had access to a complaints procedure and knew how to raise a complaint. We saw detailed records of investigations.

There were systems in place to monitor the quality of the service, which included seeking feedback from people, relatives and staff. Whilst, we found a number of shortfalls during the inspection the registered manager was positive and told us she was committed to making the necessary improvements.