About the service Belgrave Court Residential Care Home provides accommodation and support with personal care for up to 30 older people, some of whom may be living with dementia. At the time of this inspection there were 26 people using the service.
People’s experience of using this service and what we found
The service was not well led. Governance arrangements continued to be ineffective and could not demonstrate how people were safe, or how their care and support needs were being consistently met. This was the fourth consecutive inspection where the provider had not achieved a rating of good.
People's safety and welfare was compromised. People's health needs had not always been addressed as requested by healthcare professionals, and there was a delay in people receiving healthcare treatment.
Risks to people were not mitigated and people were not safeguarded from abuse and improper treatment.
The providers systems had failed to highlight the gaps in staff’s knowledge about the monitoring of peoples health and Diabetes management, and safe evacuation in the event of an emergency.
Peoples care plans and risk assessments did not contain accurate information about their healthcare risks, contained conflicting information, and did not reflect their current needs.
People were not always supported to receive their medicines as prescribed in a safe way. Recruitment processes were not robust which put people at risk of being supported by unsuitable staff.
Further work was required to ensure government guidelines for working safely in care homes during the COVID-19 pandemic were implemented, adhered to, and appropriately monitored.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Staff did not always receive effective training to support their role.
For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 10 May 2021). There were breaches of Regulations 12 (Safe care and treatment), for which we served an Urgent Notice of Decision to place conditions on the registered providers registration, and Regulation 17 (Good governance).
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection enough improvement had not been made and the provider was still in breach of regulations.
At a previous inspection published on 12 November 2019 we recommended the provider reviewed staff training, taking into account best practice guidelines. The provider had not made improvements.
At a previous inspection published on 12 November 2019 we recommended the registered provider ensured that where people lacked capacity to make a decision, the principles of the Mental Capacity Act 2005 are followed and recorded. The provider had made some improvements.
Why we inspected
We carried out an announced focused inspection of this service on 17 March and 1 April 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Safe care and treatment, and Good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective and well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Belgrave Court on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, fit and proper persons, and governance of the service at this inspection.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.