The Belfry Residential Home

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• 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

At our last inspection, we found the provider to be in breach of a legal requirement relating to their governance and oversight of the service. At this assessment, the provider has made enough improvements and is no longer of breach of this legal requirement. We reviewed 4 quality statements under this key question: Shared direction and culture, Capable, compassionate and inclusive leaders, Governance, management and sustainability and Partnership and communities. Staff were clear about their responsibilities and roles and felt supported by the management team and registered manager. Although the providers governance systems - which were used to monitor the quality and safety of people’s care - had improved and they were no longer in breach of a legal requirement, further improvements were required. Robust assurances around governance, reporting of events in the service, effective monitoring of medicines management and oversight of agency records all required improvements. The registered manager took immediate action to update agency staff records and amended their medicines auditing processes. Although we did not find these improvement needs directly impacted the safety and quality of people’s care, and any future risks were mitigated by the actions taken, time is required to demonstrate the improvements made are sustained.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All staff had undertaken training equality and diversity training. The registered managers visions and values were clearly embedded into the culture of the service and staff were equally committed and passionate about providing the right care and support to people. The registered manager had not asked the staffing team formally for feedback due to being in daily communication with staff either in supervision or at staff meetings, however following our visit the registered manager advised they have now devised staff satisfaction surveys and circulated to staff to complete.

The registered manager told us, “Our values are important to us, it is about people, offering choice, being respectful. This is their home, and we value them as people, not for profit. Our own family values we bring into our business, and we are like an extended family.” Staff we spoke to echoed those same values, spoke of the positive culture within the service, and referred to their place of work as like being in one big ‘family.’

The registered manager had a range of quality audits in place; however, the governance processes were not always effective in identifying some of the issues we found during our assessment. Although the registered manager was very responsive when we provided feedback, in order to improve the quality of the service and to keep people in the service safe, time is required to demonstrate the sustainability of these improvements by effective management.

The registered manager was extremely passionate about the service and told us, “Our care is what we pride ourselves on. We are not luxury however we are always here for everyone. The staff go above and beyond.” Staff told us they felt supported by the management team and other colleagues. Staff were also provided with training to enhance their knowledge and skill sets to provide safe care and treatment to people. Staff told us how staff morale was high due to the good working relationships they had with the management team and other colleagues. Comments included, “We do a lot of online training and in-house training. We have recently completed sepsis training, I would recommend this home, it is like a family here and a really nice home.” And “I did online training and practical training and I have completed the care certificate. We had practical manual handling training; I was supervised at all times. The training is really good. I do all online training. I have just done fire, dental course, septicaemia and skin integrity. It feels like a little family, nice environment like having loads of Nans and Grandads.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although improvements had been made since our last inspection and the provider was no longer in breach of a legal requirement, there were further improvements needed to the providers governance arrangements as these were not always identifying shortfalls found during our inspection. Shortfalls included not always notifying the relevant authorities when incidents had occurred and when concerns of a safeguarding nature had occurred. Additionally, oversight of agency staff profiles, training being completed and medicines auditing processes were poor. Although the registered manager took immediate action to update agency staff records and amended their medicines auditing processes time is required to demonstrate the improvements made are sustained.

Staff feedback was extremely positive, they told us they felt supported and listened to by the management team, comments included, “I feel supported by managers, they are very approachable and listen to what I have to say,” “We have staff meetings, we have supervision. I feel supported if I have a problem, I can speak to them about it.” And “We have a lot of staff meetings and go through anything. The management team is always talking to us. If I need anything I would talk to the manager. We do not go to the office, they come to us. We get on great with them all, we have good relationships with each other.”

People and relatives told us they were involved in what was going on within the service. Although relatives told us they were not invited to any formal relative meetings they all said they were in regular contact with service either by visiting their family member or by telephone or email. One relative told us, “Emails are sent out on holiday occasions inviting me to any event going on in the home, although I have not been invited to any official meetings, I am always kept updated about [family member].”

The service worked in partnership with the local Memory Café which enabled people to participate in activities in a different location and meet different people. The registered manager also hosted the Memory Cafe at The Belfry where members of the cafe and their families joined them for tea, cakes and games to strengthen community links. The service also worked in partnership with local schools. Other partnership groups the service worked together with were, animal groups and charities and for those people using the service where their faith is important to them, the local vicar was a great source of support.

The registered manager told us how they work together with other partner agencies and within the local community. The registered manager said, “Our residents love to see the children, we also have a preschool visit who have been coming to read and chat to the residents. We have also worked with animal groups and charities which brings out questions and interest from all residents. Especially those who are bedbound or prefer their own company. Our religious residents benefit from visits from the local vicar who has been a great support to a resident who sadly lost her husband.”

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.