Belle Vue 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 changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 62 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The management and staff ensured the service put people first and focused on their needs, wishes and aspirations.

The provider encouraged people and relatives to give feedback and make suggestions to help drive improvement and ensure the service continued to meet people’s needs. People and relatives were invited to attend regular meetings where information about the service was discussed and shared.

Staff took part in regular handover meetings where up-to-date information about people’s wellbeing and any changes to their care was shared to ensure staff had relevant knowledge to safely support people.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People, relatives and staff were involved in the running and development of the home. The provider consulted with key stakeholders through a variety of methods, to capture their views and make inclusive decisions. Staff felt enabled to make suggestions and share views about the service and felt listened to.

People, relatives and health professionals were complimentary about the registered manager. A person said, “I have spoken to the manager and she seems really nice.”

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

People and relatives told us they felt the registered manager and staff were approachable. A relative said, “The manager and the people in the office are all very approachable, very helpful, very kind and caring. Problems are dealt with fast and well.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had appropriate policies and procedures to support staff and promote equality and diversity within the workplace. The registered manager made reasonable adjustments to individual working conditions, to enable staff to do their jobs and support people effectively and consistently. The registered manager said, “If we have a pregnant staff member, we make reasonable adjustments by changing their working patterns and revising their duties.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance in all aspects of the service. Through observations and discussions with management, it was unclear who was responsible for the oversight of medicines management.

The provider had systems in place to manage and monitor the safety and quality of the service provided to people. The registered manager and senior management carried out a range of audits and checks. However, these systems were not fully effective as they failed to identify the shortfalls found during this assessment in relation to care records and medicines records/storage.

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

We received positive feedback from health professionals about the registered manager and staff. A health professional told us, “[Registered manager] is really good and very approachable. If I email her, she responds in a timely way, she supports us as we support her, to achieve the best outcomes for people.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There were effective systems and processes to ensure lessons were learned when things went wrong. Accidents, incidents and safeguarding concerns were reviewed and analysed to identify any emerging themes or patterns. Where necessary, changes were made to practice reducing the risk of recurrence and improve outcomes for people using the service.

The registered manager demonstrated a clear understanding of their responsibilities under the Duty of Candour. They were aware of the importance of being open and honest with people using the service, their families, and other relevant parties when incidents occurred that had caused, or had the potential to cause, harm.