CQC report explained · a residential care home
What the CQC found at Belvedere Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, safe medicines systems and suitable infection control. They found some risk assessments lacked enough detail, but the home was no longer in breach of Regulation 12.
- Effective?
- Good
- This key question was not inspected during this focused visit.
- Caring?
- Good
- This key question was not inspected during this focused visit.
- Responsive?
- Good
- This key question was not inspected during this focused visit.
- Well-led?
- Good
- The provider had introduced stronger quality checks and management systems. However, some staff said they were not always confident that their concerns would be heard, and the teamwork culture needed improvement.
What inspectors found, April 2021
Rated Good; inspectors found safe care and improved management, but some risk records and teamwork needed attention.
This was an announced, focused inspection. Inspectors looked only at Safe and Well-led after concerns about infection control, staffing, care and management. They reviewed records, medicines information, staff files and management documents, and spoke with people, a relative, staff and outside professionals.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, safe medicines practice and suitable infection control, including the use of protective equipment. People were supported by staff who knew them well, and the home provided activities adapted to current guidance.
Management and quality checks had improved since the last inspection. However, some risk assessments did not give staff enough detail about how to respond to particular behaviours, and some staff said teamwork and communication were not always good.
The previous overall rating was Requires Improvement. It changed to Good at this inspection. The other three key questions were not inspected, so their previous ratings were used when calculating the overall rating.
Enough staff
Inspectors found staffing levels were sufficient and were adjusted when people's needs changed.
“There were enough staff to meet people's needs.” from the report
Medicines managed safely
People received medicines as prescribed. Records were accurate, and staff training and competence were checked.
“People received their medicines as prescribed and the service had safe medicine storage systems in place.” from the report
Infection control
Staff followed infection control procedures, received relevant training and had protective equipment available.
“We were assured that the provider was using PPE effectively and safely.” from the report
Improved management checks
The provider introduced more robust checks of care plans and medicine records to identify and address problems.
“The provider had introduced a more robust quality assurance system since the last inspection which were used to drive improvement within the service.” from the report
Risk assessments lacked detail
needs fixingSome risk assessments did not clearly explain how staff should respond to agitation or behaviour that could be challenging. The provider sent updated care plans after the inspection, but inspectors had not tested whether they worked.
“Risk assessments did not have sufficient information for staff to proactively anticipate and manage risks to people who lived in the home.” from the report
Teamwork and staff communication
needs fixingThe management system had not created a consistently positive teamwork culture. The provider sent an action plan to improve openness and engagement between senior and care staff.
“Staff told us they were not always confident they would be listened to by the registered manager.” from the report
- 01How are risk assessments kept detailed and updated, especially for people who may become agitated or show behaviour that could be challenging?
- 02What training do staff receive to support people whose behaviour could be perceived as challenging?
- 03What has changed to make sure care staff feel listened to by senior staff and the registered manager?
- 04How do your quality checks identify and follow up problems in care plans, medicines records and incident reports?
- 05How are activities adapted to meet each person's needs and current guidance?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and the previous ratings were used in calculating the overall rating. This explanation was written from the published report of 15 April 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, May 2020
Rated Requires Improvement; inspectors found kind, effective care but gaps in risk records and quality checks.
This was an unannounced inspection over three days. The inspector spoke with people living in the home, relatives, staff and managers. They reviewed care plans, medicines records, staff checks, incident records and other documents, and looked around the building.
People generally felt safe and happy. Staff were caring, promoted dignity and independence, and supported people with food, healthcare, activities and everyday choices. Medicines were stored and managed safely, and improvements had been made in caring and responsive care since the previous inspection.
The main problems were incomplete or outdated risk assessments and care records. The home's checks had not found these issues, and there was no clear action plan for putting them right. The overall rating Requires Improvement means some care was good, but there was not enough assurance that risks and quality were managed consistently.
Kind and respectful staff
Staff built positive relationships with people and supported their dignity, choices and independence.
“People were supported by staff who were kind and caring. Staff had developed positive relationships with people.” from the report
Safe medicines management
The report found enough improvement for the provider no longer to be in breach regarding medicines management.
“Medicines, including controlled drugs, were securely stored and at the correct temperature.” from the report
Good food and choice
People enjoyed the food and could choose meals. The home also adapted food for medical needs and swallowing difficulties.
“People chose their daily menu options each morning. Meals were all cooked on site and the chef knew people's dietary needs and preferences well.” from the report
Activities and social life
The home provided activities every day and supported people to maintain interests, relationships and community links.
“Activities were available every day. There was a full entertainment programme throughout the whole week in both the morning and evening.” from the report
Risk records were not up to date
seriousRisk assessments were not consistently completed or reviewed. This meant staff might not have clear guidance when people's needs changed.
“People's individual safety and well-being were not assessed and recorded adequately to protect them from personal and environmental risks.” from the report
Care plans lacked detail
needs fixingSome care plans did not clearly describe people's preferences, backgrounds or the specific support they needed. One behaviour plan lacked enough detail for new or temporary staff.
“This was not fully completed and guidance for staff was not consistently clear and person centred.” from the report
- 01What action have you taken to make sure every risk assessment is reviewed when a person's mobility, health or behaviour changes?
- 02How do you check that care plans contain accurate details about each person's preferences, background and specific support needs?
- 03What is in your action plan to address the Regulation 12 and Regulation 17 breaches, and what progress has been made?
- 04How do you make sure new or temporary staff follow the correct approach when supporting someone who becomes anxious?
- 05How do your audits now identify gaps in care records and risk management before they affect people's care?
This was a planned, unannounced inspection covering all five key questions and the overall quality and safety of the home; the previous overall rating was Requires Improvement in February 2019. This explanation was written from the published report of 23 May 2020 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 Belvedere Lodge
7 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- April 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementstayed Requires improvementEffective: Requires improvement
- July 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 7 February 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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40 live-in carers within about an hour of Bristol, City of
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Most charge £1,020 to £1,300 a week. 34 can care for a couple. 11 years' experience on average.
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