CQC report explained · a residential care home
What the CQC found at Belgrave Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Belgrave Lodge was inspected but not rated; inspectors were assured about infection prevention and control during the COVID-19 pandemic.
This was an announced, targeted inspection on 28 April 2021. It looked at how the home was preventing and controlling infection during the COVID-19 pandemic.
Inspectors found good infection control arrangements. These included visitor checks, regular testing, safe admissions, appropriate protective equipment, enhanced cleaning and support for family contact.
The home supported seven people and could care for up to eight. The report gives an overall result of 'Inspected but not rated', so it does not provide a full quality rating.
Infection control
The home maintained high cleanliness standards and had an infection control lead. Enhanced cleaning and checks were carried out.
“High standards of cleanliness were maintained at the home.” from the report
Visitor safety
Visitors had temperature checks, testing arrangements, hand hygiene requirements and face masks before entering.
“Visitors were asked to provide evidence of completing a lateral flow (rapid result) swab test or they could have one carried out on the premises.” from the report
Safe admissions
Admissions were planned and included coronavirus testing for the new resident and the person supporting them.
“Admissions were planned well and promoted the safety of people who live and work at the home as well as the prospective resident.” from the report
Consistent staffing
People were supported by a consistent staff group, and agency workers were not used during the period described.
“People living at the home had been supported by a consistent group of staff.” from the report
Family contact
Staff helped people stay in touch with families by computer, telephone and face-to-face visits in line with guidance.
“Staff had supported people to keep in contact with their families using computer technology as well as through telephone calls.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now?
- 02How are visitors currently tested, screened and supported to use protective equipment?
- 03How are admissions currently planned and tested for infection?
- 04Are people still supported by a consistent staff group, without agency workers?
- 05How are face-to-face family visits arranged now?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; the service was inspected but not rated and the other care questions were not assessed. This explanation was written from the published report of 7 May 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2017
Belgrave Lodge was rated Good overall, but Safe required improvement because fire checks were incomplete and one occasional-use medicine was out of date.
This was an unannounced inspection on 4 and 7 August 2017. It was the first inspection since the home registered. One inspector reviewed care plans, medicines records, staff files, training records, audits and safety records. They also spoke with staff, a relative and community professionals, and observed people’s care.
Inspectors found kind and respectful care. People’s care plans were personalised and kept up to date. Staff supported healthcare appointments, activities, communication, choices and independence. Staff were trained and supported, and the home was well maintained.
The main concerns were about safety checks. Fire drills did not record enough information to show they were effective, and fire alarm call points were not tested often enough. One out-of-date rescue medicine was found, although a replacement was arranged during the inspection.
The overall rating was Good. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, meaning inspectors found some important safety arrangements that needed strengthening.
Kind and respectful care
Inspectors saw staff treating people with kindness, compassion, dignity and respect. Staff responded to people’s distress and supported their privacy.
“People were treated with kindness, affection and compassion.” from the report
Personalised support
Care plans gave detailed information about people’s needs, communication, preferences and wishes. They were reviewed with relevant people.
“The care plans we read were detailed.” from the report
Healthcare and staff training
People received support to attend healthcare appointments and maintain their health. Staff had structured induction, training and regular supervision.
“People received safe and effective care because staff received appropriate support and training to meet their needs.” from the report
Activities and independence
People were supported to take part in activities, go out, maintain relationships and make choices. Care planning encouraged independence where possible.
“People were supported to make choices and have as much control and independence as possible.” from the report
Fire safety checks
seriousFire drills did not include enough detail to show they were effective. Fire alarm call points in the home had only been tested five times since October 2016, and records did not show which points had been checked.
“Fire drills and weekly tests of the alarm system were not carried out effectively to make sure people were adequately protected against the risk of fire.” from the report
Out-of-date rescue medicine
seriousTwo rescue medicine syringes had expired and no in-date replacements were available when inspectors arrived. A new prescription was obtained during the inspection.
“We found both syringes had expired in April this year.” from the report
Occasional staffing pressure
needs fixingThere were occasions when only two staff were on duty, and staff said they felt stretched. Some relief staff had not arrived, so the home used staff from a sister home and was recruiting more staff.
“Staff told us they were stretched when there were only two of them to support people.” from the report
- 01How often are all fire alarm call points tested now, and can you show us the records?
- 02How do you make sure fire drills record what happened, how long they took and what was learned?
- 03How are medicines prescribed for occasional use checked for expiry dates?
- 04What happens if planned relief staff do not arrive, and how do you make sure there are enough staff on duty?
- 05What improvements have been made since the inspection to address the Safe rating of Requires Improvement?
This was an unannounced first inspection covering all five key questions, using observations, discussions and checks of selected care, medicines, staff, maintenance and audit records. This explanation was written from the published report of 8 September 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Belgrave Lodge
Each visit the CQC has published, newest first, back to the day the home was registered.
- May 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- September 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016
Registered with the Care Quality Commission on 15 January 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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