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We are carrying out a review of quality at Belgrave Care. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 14 June 2018

This inspection took place from the 3 May 2018 to the 14 May 2018 and was announced.

This service is a domiciliary care agency that provides personal care to people living in their own houses and flats in the community [and specialist housing]. It currently provides a service to older adults. Not everyone using Belgrave Care receives regulated activity; CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. At the time of the inspection we were informed that 43 people received regulated activity.

The service had a Registered Manger who was registered on the 09 February 2017. 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.

We found that some improvements were required to the service in regards to management, staffing and quality oversight which meant that there was a breach of the regulations.

You can see what action we told the provider to take at the back of the full version of the report.

The management team were open and approachable in the way they managed the service. There were quality monitoring processes in place but these were not robust enough to fully address all aspects of the service such as monitoring the time, length and reliability of calls. Staff felt under pressure as they were not always given travel time in between visits.

The registered provider was in the process of recruiting staff fill their current vacancies. In the meanwhile, this meant that people were not always supported by a consistent group of staff who arrived on time or knew them well. Processes were in place to ensure that staff recruited was of suitable character but references were not always available or concerns acted upon. We made a recommendation that processes around recruitment are reviewed to ensure they comply with the regulations.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. However, decisions were sometimes made by people who did not have the legal authority to do so which was not in line with the Mental Capacity Act. We made a recommendation that this practice was reviewed.

People received safe care delivered by staff who understood their role in safeguarding the people in their care. Risks to people's safety were assessed and a management plan put in place to keep them safe. People who received medicines were supported in a safe way as staff had the necessary training to administer medicines safely.

Care plans were comprehensive and person centred. Staff had the right information available to ensure that they provided care in line with a person’s needs and wishes.

Where people were supported with their nutritional needs, staff showed a good awareness of their dietary needs and where to get further support should this be required. Staff worked with people, their relatives and health professionals to manage people's health needs, making appropriate referrals for advice when necessary.

People told us that the staff were caring and kind. People commented that they were treated with dignity and respect and their privacy was maintained. When staff supported people at the end of their life, they worked to ensure their wishes were acted upon and supported their relatives during this time.

People were aware of how to raise concerns and complaints. Not all complaints were recorded and a record kept of actions taken.

The staff had knowledge of the Equality Act and did not discriminate against people in their care. Staff was supported

Inspection areas


Requires improvement

Updated 14 June 2018

The service was not always safe.

People did not always get their support on time and there was a lack of contingency planning for late or missed calls.

Recruitment processes were not always robust as staff started work without the required references being in place or without appropriate risk assessments.

Staff had an understanding of safeguarding and risks inherent in providing a persons care and support were assessed and managed.



Updated 14 June 2018

The service was effective.

People received care that met their needs and kept them well. Staff ensured that they sought the help and advice of other professionals in order to keep a person safe and well.

People were encouraged to make decisions about their care and were consulted in how they wished they care to be delivered. Where a person was felt unable to make a decision this made by others in their ' best interest'. However, others consented to things on a persons behalf without the legal authority to do so.

Staff received an induction, training and on-going supervision that assessed their competence and confidence in their day to day work. People felt assured that staff had the right knowledge and skills.


Requires improvement

Updated 14 June 2018

The service was not always caring.

People did not always receive care from a consistent staff group and on occasions received support from staff to whom they had received no introduction.

People and their representatives said that the staff were kind, considerate and caring. They felt that their dignity was upheld and they were respected.

Peoples individuality was acknowledged and their support tailored to their needs.



Updated 14 June 2018

The service was responsive.

Care plans were thorough and detailed and demonstrated that staff had got to know people well over a period of time. This meant that staff had the information their needed to provide personalised care.

People were supported to maintain links with family, friends and the local community.

Concerns and issues were directed to the registered manager and registered provider. People had a varying opinion as to how these were responded to.


Requires improvement

Updated 14 June 2018

The service not always well led.

The systems in place to plan staff's rotas were not robust and this meant that people did not receive care from a consistent group of staff or at a consistent time.

Checks were in place but they did not address the issues with the quality of the service found at this inspection.

The management team were visible and accessible to staff and people whop used the service. Opportunity was made available for feedback to be given on the service received.