Belvidere Court Nursing 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 82 (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.

The registered manager and the staff team recognised people’s diversity and worked closely with them to ensure they had created a culture where everyone was involved.

The registered manager was focused on delivering a positive culture which they had created within the home. There were processes in place to ensure there was a positive culture in the home. This included ensuring people and staff were supported, had the right skills and knowledge, encouraged and involved to promote a positive culture. The registered manager told us it was important that people and relatives were involved with all aspects of their care and the running of the home. They told us how they recently refurbished the flooring in some areas of the home. They had implemented a voting system where people, staff and relatives could choose their preferred colours/flooring from suitable flooring that had been identified. The registered manager had collated all the information and feedback and used this to select the flooring. One staff member told us, “It was good to involve everybody”. This demonstrated the inclusive culture of the home.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

All people, relatives and staff spoke positively about how the home was run and the registered and deputy manager. One person said, “It’s good here, it’s a good nursing home”. A relative said, “I have no complaints. I would tell the manager if I did have”. Another relative told us, “I would recommend here. The manager chats with me about his care, especially when [relation] came in. They have spoken to me about a better chair for him to keep him comfortable. It’s well run. It’s good they recognise changes in him, in his muscle tone, hence the better chair”.

The registered manager had introduced effective ways to manage staffs’ progress and performance. The registered manager ensured all staff had individual supervisions that were based on learning and improvement. Supervisions and staff meetings were tailored to themes that had occurred in the home, learning outcomes or training requirements, such as when a safeguarding had occurred the registered manager had adapted supervisions around this to ensure all relevant information was shared and discussed in the team meeting. A nurse told us, “We always focus on something, it can be the Mental capacity act, something clinical that has changed, something that maybe better for people, anything really we are just always trying to get better and learn”.

In addition, the registered manager conducted regular reviews of staff which considered their performance, punctuality and sickness. The registered manager worked with staff to ensure development was identified and support plans were implemented where needed.

There were systems in place to ensure all staff understood their roles and responsibilities and there were clear lines of delegation. We had been notified of events that had happened within the service in line with the provider’s legal responsibility to so do.

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

People and relatives confirmed they knew how to complain. Staff felt able to report any concerns and confirmed they would be supported during any such time.

There was a whistleblowing policy in place and staff were aware of this and the procedures they needed to follow. They were actively encouraged by the registered manager and other team members to identify and raise concerns if needed to create an open, honest and transparent culture within the home.

The provider valued diversity in their workforce.

Staff felt they were treated in an inclusive way, and their diverse needs were considered. Staff spoke positively about their experiences and shared that it was a good place to work. One staff member told us, “It’s a really good place to work, we all support each other well and get on well together. We are encouraged to be involved with peoples care and that helps us feel valued”.

The provider had clear responsibilities, roles, systems of accountability and good governance.

There were audits in place which monitored the care people received, including medicines management, peoples care including their weights and fluid intake and the environment. There was also a system in place to monitor and review incident and incidents that had occurred. These audits were effective in identifying areas of improvement and making changes where needed.

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

There were systems in place to ensure the provider worked in partnership with other agencies and professionals to ensure care was safely delivered to people. As part of this assessment, we reviewed professional feedback, the information we received and viewed was positive. One professional told us, “I find the home are very responsive, if I ask for information, it is shared promptly and the detail is usually to a very high standard”.

The registered manager shared with us the innovative ways they had worked in partnership with other agencies to develop positive outcomes for the people they supported. For example, the registered manager had recognised that a better working relationship could be developed between themselves and paramedics that came into the home. They had introduced a feedback sheet that they gave to the paramedics which gave them the opportunity to offer feedback on their visit and raise anything of concern. The registered manager told us they then reviewed this feedback to see if anything could be changed to embed further improvements. They also told us this had reduced the number of safeguarding concerns that had been reported by visiting paramedics.

The registered manager and the home worked with a range of external agencies to offer opportunities for professionals. This included working alongside universities to offer student nurse and Occupational Therapist placements that could aid their development. The registered manager told us how 1 of their current nurses had worked at the home on a student placement and now had a permanent job working in the home as a nurse. The provider also worked alongside a local college to offer work experience to students who were interested in health and social care.

Staff engaged with local communities and worked with the local school whose pupils came into the home and completed activities with people and at Christmas a singing event took place. We saw photographs of people participating in these activities, 1 person told us, “I enjoyed that day”. This showed the provider had worked in partnership with local communities to develop strong relationships which people enjoyed.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

We found a culture of continuous learning and improvement. There were systems in place which were used to drive improvements throughout the home. For example, the deputy manager told us how previously a safeguarding had been raised by a professional as a piece of equipment that was being used was not in line with best practice. The home had acted on this and changed their practice, which meant more suitable equipment was used in these instances within the home. The deputy manager had created a poster which was displayed around the home which showed the concerns, the action taken and the learning from this. This was displayed for everyone to see. The deputy manager told us, “It’s important to be honest and share when things have not been quite right, but by doing this they can also see how we have acted.”

The provider had developed a system which monitored the activities people participated in. The care people received was clearly documented and reviewed, including the activities they participated in. Staff observed and recorded people’s levels of engagement and response to the activities they had participated in as well as the amounts of time they had completed these. Staff then analysed this information each month and identified the positive or negative effects this had on each person. They then used this information to tailor activities to meet people’s individual needs. The activities coordinator told us their innovation and hard work around activities with people had been recognised when they had been awarded a best activities award at the local Care Association awards.

The service had been proactively involved with hydration week which was an innovative way to encourage people to drink more fluids. As part of the week, on different days people were supported to participate in tasks that encouraged them to drink. This included, ‘mocktail’ day and making and eating jellies. We saw photographs of people participating in this, 1 person who we showed the photographs to confirmed they had enjoyed it. Staff spoke of the benefits to people for this and 1 staff member told us, “There are loads of benefits of people drinking more, it’s something we try and encourage all the time here, but this was a more fun way of involving people”.

When incidents had occurred, the registered manager ensured lessons were continually learnt and there was a continual emphasis on developing an improved service for people. The process ensured all members of the staff team were actively involved, which gave them ownership of the changes that were introduced.