Belvidere Residential Care Home

Updated 10 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by one inspector, an assistant inspector, a specialist advisor and an Expert by experience who undertook telephone calls. The specialist advisor was a nursing professional. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Belvidere is a residential care home. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Belvidere residential care home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 10 March and ended on 31 March when feedback was provided. We visited the service on 10 and 15 March 2022. The Expert by Experience called relatives on 11 March 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection-

We spoke with five people who used the service about their experience of the care provided. We telephoned and spoke with 10 relatives to gain feedback about their loved one’s care. We also spoke with 10 staff which included care and senior staff, domestic and laundry staff, the administrator, deputy manager, registered manager, and regional manager.

We reviewed a range of documents and records including the care records for eight people, 20 medicine records, three staff recruitment files. We also looked at records that related to the management and quality assurance of the service.

After the inspection

We continued to seek clarification from the registered manager to validate evidence found.

Updated 10 May 2022

About the service

Belvidere is a residential care home providing personal care and accommodation for up to 28 people some of whom may live with Dementia. The service was supporting 23 people at the time of the inspection in one adapted building.

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

Improvements were required with the systems in place to manage people’s medicines. This is to ensure people received their medicines as prescribed and records supported when these were given to people. Risks to people were not consistently well managed and left people at potential risk of harm. Safeguarding procedures were in place but required further improvements to ensure they included all aspects of potential abuse. We were somewhat assured with some of the measures in place to prevent the spread of infection.

Improvements were required with the systems in place to submit and manage deprivation of liberty applications and authorisations. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not always support this practice.

Timely action was not always undertaken to ensure people’s healthcare needs were addressed. Although staff received training for their role, they would benefit from more in-depth training to support people with complex needs. The environment was not always dementia friendly and homely and lacked signage to enable people to orientate themselves. A renewal programme was in place and improvements were being made.

The systems and processes in place were not robust to enable the provider to identity where areas for improvement were needed and to take action to address these. The registered manager did take immediate action when information of concern was shared with them to protect people from potential harm.

Staff felt supported in their role. Systems were in place to support people to maintain contact with their loved ones. People and relatives were happy with the care provided. The registered manager was described as approachable, open and transparent. The registered manager demonstrated a commitment to make the improvements required.

Rating at last inspection: The last rating for this service was good (published 22 November 2018).

Why we inspected

We received concerns in relation to the management of medicines and people’s care needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. 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 good to requires improvement based on the findings of 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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report. The provider had started to take action to mitigate the risks we had identified.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Belvidere residential care home on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified breaches in relation to the management of medicines, and risk and to the overall governance of the service. We have issued the provider with a warning notice.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.