CQC report explained · a residential care home
What the CQC found at Belgravia Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found kind, responsive care, but safety checks, medicines management and oversight needed improvement.
Inspectors visited the home on 23 May and 9 June 2022. They spoke with people, relatives and staff, and reviewed care records, medicines records, recruitment files and management records.
People generally said they felt safe, cared for and respected. Inspectors rated the home Good for effective, caring and responsive care. Staff supported people's choices, provided activities, helped with food and drinks, and sought medical advice when needed.
Safety was not consistent. Some window restrictors were unsafe, lifting equipment checks were overdue, medicines records and practice needed improvement, and some areas needed cleaning. The home was also rated Requires Improvement for being well-led because audits had not found or fixed these problems.
The home was rated Requires Improvement overall. Inspectors found two legal breaches. Some action was taken during the inspection, and the provider was asked for an action plan so progress could be monitored.
People felt safe
People told inspectors they trusted staff and received help quickly when needed. Staffing arrangements had improved through the use of a formal assessment tool.
“I trust the staff, they look after me.” from the report
Kind and respectful care
Staff supported people's dignity, privacy, independence and preferred routines. People were involved in everyday decisions and in planning their care.
“I have my own routine and I like it like that. The staff fit in with that.” from the report
Activities and relationships
People enjoyed activities and were supported to maintain relationships and receive visitors.
“We go down to the games room and do activities. Bingo, cards, it keeps us busy.” from the report
Staff support and training
Staff completed induction and training and said they received supervision. People were supported with meals, drinks and access to healthcare.
“Staff completed an induction on starting to work at the home and this included shadowing an experienced member of staff so they gained knowledge and learnt people's needs and wishes.” from the report
Unsafe window restrictors
seriousTwo occupied rooms had window restrictors that were not tamperproof and allowed windows to open more than 100mm. Inspectors said this created a risk of falls from height.
“This placed people at risk from avoidable harm from falls at height as restrictors were not tamperproof and windows could be opened to more than 100mm.” from the report
Equipment checks
seriousSome slings used with hoists had not received the required six-monthly checks by a competent person. The equipment was examined and serviced before the inspection ended.
“Slings which are used with hoists to support peoples' mobility were not subject to the required six monthly checks.” from the report
Medicines management
needs fixingThe medicines trolley temperature was not monitored, the trolley was not secured to the wall, and medicine stock counts did not match records. Inspectors also saw poor practice while a medicine was being prepared.
“The stock count of three medicines did not match the amount recorded as remaining.” from the report
Cleaning and infection control
needs fixingInspectors found poor cleaning and infection control practices, including a staff member wearing a mask under their chin and clean laundry placed near a mop. The home took action during the inspection.
“We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Audits did not find problems
seriousManagement checks had not identified several safety, infection control and record-keeping shortfalls. This led to a breach of the good governance regulation.
“These did not always drive improvement.” from the report
Incomplete care records
needs fixingTwo care records lacked consistent or sufficient information about how to support people safely and respond to changes in mood. The provider was advised to improve person-centred recording.
“In a second care record, there was a lack of information in the person's care plan to guide staff on the action to take in response to a change in mood.” from the report
- 01What checks now confirm that every accessible window has a tamperproof restrictor that limits opening to 100mm?
- 02How often are hoists and slings checked by a competent person, and can you show the latest records?
- 03How are medicine trolley temperatures, security, preparation and stock counts checked now?
- 04What extra audits were introduced after the inspection, and what problems have they found and fixed?
- 05How have the two care records identified by inspectors been corrected, and how do you check that other records contain clear, person-centred instructions?
This was the first comprehensive inspection, covering all five key questions; an earlier focused inspection between 11 and 16 August 2021 looked only at Safe and Well-led and gave no overall rating. This explanation was written from the published report of 30 June 2022 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 2021
Belgravia Care Home was inspected but not rated overall; Safe and Well-led both Requires Improvement, with unfinished fire safety work.
This was a focused inspection after concerns about staffing and fire safety. Inspectors visited on 11 and 16 August 2021. They spoke with people, relatives, staff and managers, and checked records and the home.
People said they felt safe and received help promptly. Inspectors found medicines, recruitment checks, infection control and risk assessments were generally managed safely. However, fire safety improvements were still unfinished, and the provider needed a better way to decide staffing levels.
The home was rated Requires Improvement for Safe and Well-led. There was no overall rating because inspectors only examined those two areas. The other three areas were not inspected during this visit.
Prompt support
People said they received help when needed. Inspectors saw call bells answered quickly and staff responding to people's needs.
“During the inspection call bells were answered quickly and staff were responsive to people's needs.” from the report
Medicines management
Medicines were handled by trained staff whose competence had been checked. Medicines were stored securely.
“Medicines were managed by staff who were trained in the management of medicines and their competency assessed.” from the report
Infection control
Inspectors were assured that the home used protective equipment, supported testing and visits, and had suitable infection prevention arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
People's views
People were asked for their views and the home acted on feedback, including arranging more evening activities.
“Surveys were provided to gain people's views and action taken.” from the report
Fire safety work unfinished
seriousFire safety concerns had been identified by the fire service, but required building work and specialist equipment were not complete when inspectors visited. This created an increased risk until the work was finished.
“This work had not been completed at the time of the inspection, we will check with Lancashire Fire and Rescue Service and the provider, that all required work is carried out within the specified timescales.” from the report
Weak quality checks
needs fixingThe provider's audits had not identified problems such as wedged-open fire doors and doors that did not fit correctly. The governance system therefore did not consistently drive improvements.
“Areas of concerns identified by Lancashire Fire and Rescue Service had not been identified through audits.” from the report
Staffing calculation
needs fixingInspectors found staffing was sufficient during the visit and had recently increased. They nevertheless recommended using an effective tool to identify how many staff were needed.
“We recommend the provider seeks and implements an effective staffing tool, which will help identify the number of staff required to support people who live at the home.” from the report
- 01Has all the fire safety work identified by the fire service now been completed?
- 02Are any fire doors still wedged open or not fitting correctly?
- 03What staffing tool is now being used to decide how many staff are needed on each shift?
- 04How often are fire safety and other quality audits completed, and how are actions checked?
- 05What improvements have been made since this inspection and what evidence can you show families?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and there was no overall rating. This explanation was written from the published report of 22 September 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.
Every inspection of Belgravia Care Home
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- June 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2021Inspected but not ratedSafe: Requires improvementWell-led: Requires improvement
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021
Registered with the Care Quality Commission on 15 March 2021.
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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