Belvoir Vale Care Home

Belvoir Vale Care Home is a residential care home providing personal care to up to 62 people. The service provides support to older adults some of whom were living with dementia. At the time of our inspection there were 52 people using the service.

People’s experience of the service and what we found:

People were protected from the risk of abuse and neglect. Risk assessments relating to health conditions were detailed and clearly directed staff what action they should take in order to support people safely. Staff were recruited safely and there were enough staff deployed to meet people’s needs. Medicines were managed safely. The home was exceptionally clean, and people were protected from the risk of infections. Lessons were learnt when thing went wrong.

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; the policies and systems in the service supported this practice.

People and their relatives told us; they were exceptionally happy with the care provided and described staff as ‘Angels’. Staff sought information about each person's individuality, skills, cultures, and lifestyle choices which allowed staff to celebrate and focus on areas which were important to people. Staff encouraged, empowered, and supported people to share their views. People were always treated with the highest level of respect and with their dignity preserved.

Personalised care was at the heart of the service. Activities were truly person centred. Staff supported people to socialise, and take part in activities which were significant to them. People’s concerns and complaints were exceptionally well listened to, responded to, and used to improve the quality of care. People were exceptionally well supported at the end of their life to have a comfortable, dignified and pain free death. People’s communication needs were well understood and supported.

People were undoubtedly at the heart of everything at Belvoir Vale. People, relatives, staff. and professionals told us the management team and the environment they had created was exceptionally supportive. The registered manager was passionate, motivated, and determined to achieve the best possible outcomes for people. People and staff were fully engaged in the running of the service. Feedback from both people and staff was excellent. The provider worked exceptionally well in partnership with others.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 4 April 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook a focused inspection to review the key questions of safe, caring, responsive and well-led only. For the key question not inspected, we used the rating awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Belvoir Vale Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The provider ensured all visitors to the home provided evidence of a negative LFT result. Professionals were required to provide proof of COVID-19 vaccinations. An electronic monitoring system reminded visitors to wear a mask and also took their temperature prior to entering the home. People had access to visitors when they wanted them. Essential care givers were permitted further access to the home to support staff with caring for their relatives.

There were ample supplies of PPE throughout the home. Staff wore PPE when required. PPE stations were placed around the home for easy access. Used PPE was disposed of safely. Efforts had been made to encourage social distancing. For example, dining tables were limited to three people and chairs in communal areas had been separated. Safe isolation procedures were in place. The layout of the home with three separate buildings meant access to some parts of the home could be restricted, reducing the risk of the spread of infection.

The domestic staff had cleaning schedules in place. The quality of their work was reviewed via regular auditing. We observed the home was visibly clean and tidy.

People were admitted to the home in a way that reduced the risk of the spread of COVID-19. All new admissions had to meet required vaccination status and negative LFT result before entry was granted to the home.

Increased support from staff was in place to support people living with dementia to maintain social distancing. Posters were placed around the home offering guidance and information for people and staff advising them how to spot the signs of COVID-19 and to help to reduce the risk of spreading it.

All staff and people living at the home were tested regularly and in accordance with government guidelines. The provider had ensured staff were fully vaccinated in order for them to carry out their role.

There were enough staff to support people safely and to cover any staff holidays, sickness and COVID-19 isolation. Agency staff had been used where needed.

The provider considered staff member’s wellbeing. A variety of initiatives were in place to thank staff for their support.

Occasionally, non-care staff have supported care staff with their roles, for instance during busy periods or if a staff member was off work sick. Regular COVID-19, outbreak and other related audits were carried out to help identify any areas of concern. Action plans were in place and reviewed.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

We found the following examples of good practice.

¿ The provider had refurbished the one building to ensure effective use of cohorting and zoning to reduce the potential for the infection to spread. Staff were appointed to work in this designated area which was completely separate from the main buildings, further reducing the potential for transfer of infections.

¿ There was a detailed entry system into the home, with temperature testing, contact questionnaire and hand disinfection. Any people being admitted to the home had an exclusive entrance which allowed swift transfer to their appointed area.

¿ The provider ensured there was a plentiful supply of personal protective equipment such as masks, gloves, aprons and hand sanitiser. We saw staff used this appropriately.

¿ The provider participated in regular testing of staff and people living in the service for COVID-19. That ensured action could be taken swiftly to reduce the potential spread of infection if a positive test was returned.

¿ Areas were thoroughly cleaned and disinfected with approved products to reduce the potential of transfer of infection. Staff were aware of the process to disinfect floors and hard surfaces.

¿ Risk assessments had been completed to protect people and any staff who may be at higher risk if they contracted COVID-19. Measures were in place to support them. Staff were supported by regular information updates and the option of accessing wellbeing support.

Further information is in the detailed findings below.

At our last inspection we rated the service Good. At this inspection, we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People continued to feel safe and staff ensured that risks to their health and safety were reduced. Although there were some concerns around staffing levels, the management team had already begun to address this just prior to the inspection using the company’s staff monitoring tools. That allowed them to re-evaluate staffing levels. Following our inspection, the registered manager informed us the levels had been increased to meet the needs of people at the service.

People were protected from the risks of infection as the service provided sufficient cleaning hours to ensure the environment was clean. Staff had received appropriate training to ensure they had the knowledge to protect people whilst providing care. Systems were in place to support people to take their medicines.

Staff received relevant training and felt well supported. People were asked for their consent and appropriate steps were taken to support people who lacked capacity to make particular decisions. People were supported to eat and drink enough to maintain good health.

There were positive and caring relationships between people and the staff who cared for them. Staff promoted people’s right to make their own decisions and respected the choices they made. People were treated with dignity and respect by staff who understood the importance of this.

People received person-centred and responsive care from staff who had a clear understanding of their current support needs. Care plans were in place, which provided information about the care people required. People knew how to make a complaint and there was a clear complaints procedure in place.

When people were at the end of their life the service had effective measures in place to support them and ensure their wishes and needs were met.

An open and transparent culture enabled people and staff to speak up if they wished to. The management team provided strong leadership and a clear direction to staff. The service worked to ensure lessons were learned from adverse incidents. There were robust quality monitoring procedures in place.

Further information is in the detailed findings below.

All of the people we spoke with told us they received good quality care when they needed it. They all told us they received care that met their needs. One person said, "I get the care I need, they are excellent here, the carers." People we spoke with all said their health care needs were met well at the service and we observed care being delivered to people in line with the plan of care ensuring people's needs were met.

We looked at the premises and the safety and suitability of equipment and we found the home was comfortable and odour free. The people we spoke with all told us the home was well maintained. One person commented, "Any repairs are done quickly."

We observed that people had the equipment they needed to meet their needs and to keep them safe and there were records to show that equipment was serviced regularly to make sure it was safe for use.

None of the people we spoke with had complained but they all said they felt any concerns would be investigated and responded to. One person told us, "I would complain if I needed to, but the staff seem very kind, I have never seen any of them misbehaving." We saw that any complaints were recorded and responded to in line with the company policy.

We haven't spoken to people using the service because the compliance action was to do with making sure the right records were in place. However, we saw evidence in the files we looked at to show both staff and the doctor had spoken with people living at the service about their resuscitation wishes. These were clearly recorded and provided evidence of consultation and involvement in decision making where this was possible. We found that the compliance action had been met.