CQC report explained · a nursing home
What the CQC found at Belvedere House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risk assessments, staffing, recruitment, medicines, infection control and accident responses were found to be well managed.
- Effective?
- Requires improvement
- Some mental capacity assessments were not specific to individual decisions. Best-interest decisions and less restrictive options were not always properly recorded.
- Caring?
- Good
- People described staff as kind and caring. Inspectors saw staff treating people with dignity, involving them in decisions and supporting their independence.
- Responsive?
- Good
- Care plans recorded people's preferences and needs. The home offered daily activities, responded to complaints and provided personalised end of life care.
- Well-led?
- Good
- The home had an approachable manager, regular audits and an open culture. However, its audits had not identified the mental capacity law problems before the inspection.
What inspectors found, June 2019
Rated Good; inspectors found safe, kind and responsive care, but the home did not always follow mental capacity law.
This was an unannounced inspection on 15 April 2019. Inspectors reviewed records and policies, spoke with people living there, relatives, staff and volunteers, and checked staff files.
The home was rated Good overall. Safe, caring, responsive and well-led were rated Good. Inspectors found well-trained and attentive staff, personalised care plans, safe medicines practice, varied food and activities, and good complaint handling.
Effective was rated Requires Improvement because some mental capacity assessments were too general and did not properly record decision-making or consider less restrictive options. The manager introduced new assessment and best-interest forms immediately after the inspection.
Safe care and medicines
Inspectors found comprehensive risk assessments, suitable staffing and safe recruitment. Medicines were administered as prescribed and records had no gaps.
“Medicine administration records (MARs) had been filled out correctly and with no gaps.” from the report
Kind and respectful staff
People were treated with kindness, dignity and respect. Staff took time to talk with people and supported their independence.
“People told us that they were supported by kind and caring staff.” from the report
Personalised activities and care
Care plans included personal details and preferences. People could take part in varied activities, outings and dementia-friendly games.
“People took part in interesting and meaningful activities each day of the week.” from the report
Open management
The manager was approachable and encouraged feedback from people, relatives and staff. Regular meetings and surveys helped shape menus and activities.
“The registered manager had an open-door approach for people, staff and relatives.” from the report
Mental capacity records
seriousSome assessments were too general rather than relating to a particular decision. The report also found no recorded best-interest consideration for one person's bed rails.
“People's rights were not always protected because some mental capacity assessments were not decision specific.” from the report
- 01Have all residents' mental capacity assessments now been completed for each specific decision?
- 02How do you record best-interest decisions when restrictions such as bed rails are considered?
- 03How do you make sure the least restrictive option is used for each person?
- 04What checks now confirm that mental capacity records remain legally compliant?
- 05What changes have been made since the inspection, and what evidence can you show of this progress?
This was a planned, unannounced inspection covering all five key questions and the overall quality and safety of the care home. This explanation was written from the published report of 14 June 2019 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, October 2016
Rated Good; inspectors found safe, kind and person-centred care, with strong dementia support and leadership.
The unannounced inspection took place on 27 July 2016. Inspectors spoke with 15 people, four visitors and 12 staff. They also used observations for people who could not describe their care, reviewed care files, recruitment and training records, and spoke with health professionals.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable staffing, safe medicines management, trained staff, person-centred care and strong support for people living with dementia.
The report describes a well-maintained home with varied activities, good links with health professionals and an effective complaints process. It says the previous inspection in December 2013 found that all the regulations checked at that time were met.
Staffing and teamwork
Staffing levels were based on people's needs and allowed care to be given without rushing. Staff across nursing, care, housekeeping, catering and maintenance worked together.
“Staffing levels considered fully the support needs of people and calculated accordingly. As a result staff were present in such numbers as to support people in an unhurried manner.” from the report
Dementia support
The home used specialist advice, reminiscence resources, music and sensory areas to support people living with dementia. Inspectors said this helped people's wellbeing and quality of life.
“The dementia needs of people were fully considered and positive outcomes were experienced.” from the report
Kind and individual care
Staff understood people's personalities, backgrounds and preferences. They involved people in decisions and gave them time and reassurance.
“The service was caring. people were consistently treated with empathy, kindness and compassion.” from the report
Food and drink support
The home identified people at risk of poor nutrition or dehydration and used snacks, drinks and individual support to help them eat and drink well.
“There was a strong emphasis on the importance of eating and drinking well.” from the report
Activities and community links
People could take part in activities, outings and social events suited to their interests and abilities. Families, volunteers and community organisations were also involved.
“There was an exceptional programme of activities and social events meaning people had opportunities to be occupied and stimulated.” from the report
Inspectors raised no specific concerns in this report.
- 01How are staffing levels currently calculated for each shift, and how are sickness and other short-notice absences covered?
- 02How are medicines checked and audited now, and which staff are trained and assessed as competent to administer them?
- 03How will you involve my relative and our family in care planning, monthly reviews and the six-monthly family reviews?
- 04What dementia activities, music sessions, reminiscence resources and outdoor facilities are currently available?
- 05How are complaints investigated, and when would you involve someone independent of the home?
This was an unannounced inspection of the overall service and all five CQC questions, using conversations, observations, records and feedback from health professionals. This explanation was written from the published report of 20 October 2016 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Belvedere House
2 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
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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