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Belvoir House Requires improvement

The provider of this service changed - see old profile


Inspection carried out on 2 September 2019

During a routine inspection

About the service

Brundall Care Home is a residential care home providing accommodation and personal care for up to 39 people. At the time of the inspection visit there were 37 people living in the home, the majority of whom were living with dementia. Accommodation is over two floors and the home has been divided into two areas called Nightingale and Kingfisher.

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

Risks to people’s safety had not always been assessed or managed appropriately which placed them at risk of avoidable harm, and the systems in place to protect people from the risk of abuse had not always been effective at doing this.

People’s consent had not always been sought in line with the relevant legislation and therefore, people had not been fully supported to have maximum choice and control over their lives.

The governance systems and leadership in place had not been fully effective at monitoring the quality of care people received and therefore, reducing risks to their safety. CQC had not been notified of important incidents as is required by law.

People received enough food and drink to meet their needs although the dining experience required improvement to ensure it was a pleasant experience for all. People received their oral medicines when they needed them but some improvements were required to the recording of prescribed creams.

Staff had received training in various subjects and received regular supervision however, this needed improving as we found a number of issues with staff practice during this inspection.

The staff were kind and caring when they interacted with people although the provider had not ensured the service had a consistently caring approach and this needed improving. There were enough staff to meet people’s needs but some of the required checks to ensure they were of good character before they started working at the service had not occurred.

People and relatives were happy with the care they received and told us this had improved under the new provider’s leadership and people had access to regular activities to provide them with stimulation.

The service had ensured that people and relatives were involved in the planning of care and had taken steps to ensure care was delivered to meet people’s individual needs and preferences. Some improvements are required with regards to the planning of people’s oral healthcare and we have made a recommendation in this area.

The home and equipment people used was clean and the environment had been adapted to meet the needs of the people living in the home. Any concerns or complaints raised had been listened to and acted on and people and relatives had been actively engaged in the running of the service and their opinion valued.

Staff ensured people were supported with their health needs and worked well with other professionals when required, this included when people reached the end of their life.

Rating at last inspection

Brundall Care Home was purchased by a new provider in 2018. Under the old provider, the home had been rated as Inadequate. This was the first inspection under the new provider’s ownership.

Why we inspected

This was a planned inspection based on the date the provider registered with us.


We identified five breaches of regulation at this inspection. This was in relation to the assessment and management of risks to people’s safety, the systems in place to protect people from the risk of abuse, obtaining consent in line with legislation, governance systems for monitoring and improving quality of care and notification of incidents to CQC.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.