Belvedere Lodge

Updated 15 April 2021

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 Care Act 2014.

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 team consisted of two inspectors.

Service and service type

Belvedere Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was announced. Inspection activity started on 11 February 2021 until 26 February 2021. One inspector visited the location on 11 February 2021. One carried out the inspection remotely.

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. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We reviewed the provider’s previous inspection reports. We used all of this information to plan our inspection.

During the inspection

We spoke with two people and received feedback from one relative. We looked at four people’s care records and four medicine administration records (MAR). We spoke with the registered manager and five staff which included, deputy manager, chef and carers. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We received feedback from two professionals who regularly visit the service.

Updated 15 April 2021

About the service

Belvedere Lodge Residential Care Home provides accommodation and personal care for up to 20 older

people, some of whom were living with dementia. People who live at the home access nursing care through

the local community healthcare teams. At the time of the inspection 14 people were living at the home.

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

People living at Belvedere Lodge received safe care from skilled and knowledgeable staff. Staff knew how to identify and report any concerns. The provider had safe recruitment and selection processes in place.

Risks to people's safety and well-being were managed through a risk management process. There were sufficient staff deployed to meet people's needs. Medicines were managed safely, and people received their medicines as prescribed.

The provider’s care recording system had improved. People had access to meaningful activities which had been adapted in line with current guidelines. Staff consistency enabled people to receive good care from staff who knew them well. Staff knew how to support people during end of life care.

The home was managed by a registered manager who had been in post since the last inspection and was committed to improving people’s quality of life. The service had a management and staffing structure in place. However, this was not always clear to staff and as a result they were not always working well as a team. The provider had established an effective quality assurance system to monitor the quality and safety of the service. The service worked well with external social and health care professionals.

Rating at last inspection

The last rating for this service was requires improvement (Published 20 May 2020).

At this inspection we found improvements had been made.

Why we inspected

We carried out an announced inspection of this service on 11 February 2021. We received concerns in relation to infection control procedures, poor staffing, poor care within the service and poor governance systems. As a result, we undertook a focused inspection to review the concerns raised within the key questions of Safe and Well-led only.

We looked at infection prevention and control measures. 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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. We announced our inspection and requested information relating to infection prevention control policies, audits, contingency plans, staff training in infection control procedures and visiting policy during the COVID pandemic. We found no evidence during this inspection that people were at risk of harm from these concerns.

The ratings from the previous comprehensive inspection were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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