CQC report explained · a nursing home
What the CQC found at Belvidere Nursing Home Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Infection control was not initially robust, and medicines were not always managed safely. Risk information, incident records and safeguarding records also needed improvement, although staff recruitment checks were completed and there were enough staff on duty.
- Effective?
- Good
- This area was not inspected during this visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks and governance systems did not identify or address the problems found. Care records were not always accurate or up to date, and the manager needed more knowledge of regulations and best practice.
What inspectors found, April 2021
Rated Requires Improvement; inspectors found serious infection control, medicines and record-keeping problems, alongside kind care and enough staff.
This was an unannounced inspection in February 2021. It began after concerns about infection control and COVID-19. Inspectors first looked at infection control, then widened the inspection to medicines, records, leadership and oversight.
The home acted quickly after the first visit and infection control had improved three days later. However, inspectors found that infection procedures had not initially protected people. Medicines were not always managed safely, staff medicine skills had not been properly checked, and care records were not always accurate or up to date.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used. The previous overall rating was Good in September 2018.
Enough staff
Inspectors found enough staff on duty to meet people's needs. Recruitment safety checks had also been completed.
“On the day we visited, there were enough staff on duty to meet people's needs.” from the report
Kind and attentive care
Relatives said staff were kind, caring and attentive. The report also found that staff knew people well and tailored care to their preferences.
“The manager and staff team were person centred. They knew the people they looked after really well” from the report
Infection control action
The manager acted immediately after the first visit, and inspectors saw improvements three days later. The work was still ongoing at the time.
“In response to the concerns we identified, the manager acted immediately to improve infection control standards within the home.” from the report
Support for wellbeing
Inspectors found that people’s wellbeing was supported with help from health and social care professionals.
“People's well-being was supported in partnership with other health and social care professionals, such as GP's, District Nurses and Mental Health Teams.” from the report
Infection control
seriousCOVID-19 and infection control procedures were not always robust or followed. Staff training and risk assessments were also not sufficient.
“Infection control within the home did not protect people from the risk of, or, spread of infection.” from the report
Medicines
seriousMedicines were sometimes removed from their original packaging, records were signed by staff who had not given or observed the medicine, and staff competency had not been properly assessed.
“Unsafe management of medicines places people at risk from serious harm.” from the report
Care and incident records
needs fixingSome care plans and daily records were repetitive, incomplete or out of date. Records of accidents, incidents and safeguarding did not show clearly what action had been taken or what had been learned.
“A lack of accurate record keeping in places people at risk of inappropriate or unsafe care.” from the report
Weak oversight
needs fixingAudits and governance systems did not identify the problems found during the inspection. There was little evidence of provider oversight.
“The audits and governance arrangements in place were ineffective.” from the report
- 01What changes have been made to infection control and COVID-19 procedures since the inspection?
- 02How are staff now assessed as competent to administer medicines safely?
- 03How are medicine records checked to make sure the person giving the medicine signs the record?
- 04How are care plans and daily records kept accurate and updated without delay?
- 05What audits now check infection control, medicines, incidents and record keeping, and how are actions followed up?
This was a targeted inspection of infection control followed by a focused inspection of Safe and Well-led; the Effective, Caring and Responsive ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 27 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, November 2020
Belvidere Nursing Home Limited: inspected but not rated; inspectors found good infection-control practice, but this was not a full care-quality inspection.
This was an announced, targeted inspection on 20 October 2020. It looked at infection prevention and control during the COVID-19 pandemic.
Inspectors found current infection-control guidance, staff training and checks, suitable personal protective equipment, increased cleaning and regular monitoring. They were assured that the home was managing visitors, social distancing, admissions, testing and possible outbreaks safely.
People said staff wore the correct protective equipment and that they felt safe. Staff supported people to keep in touch with family and friends through telephone and video calls.
The home was inspected but not rated. This means the report does not give a full overall rating or ratings for most areas of care.
Staff infection-control training
Staff received current guidance, training and regular checks so they understood how to follow infection-control procedures.
“Staff completed IPC training and regular competency checks to ensure they followed correct procedures and knew how to keep people safe during the COVID-19 pandemic.” from the report
PPE and cleaning
Protective equipment was clearly available and staff were seen using it correctly. COVID-19 risk assessments and increased cleaning schedules were in place.
“Well stocked and clearly signed personal protective equipment (PPE) stations were located around the service.” from the report
People felt safe
People said staff wore the correct PPE and that they felt safe living in the home.
“People told us staff always wore the correct PPE and they felt safe living at Belvidere.” from the report
Contact with families
Staff helped people keep in touch with relatives and friends through telephone and video calls, while planning controlled visits.
“People received support to stay in touch with family and friends through telephone and video calls.” from the report
Inspectors raised no specific concerns in this report.
- 01How are infection-control procedures, PPE supplies and cleaning schedules being monitored now?
- 02How are visitors currently managed, and what guidance and protective equipment are they given?
- 03How are people supported to keep in contact with family and friends if visits are restricted?
- 04What are the home's current ratings or inspection findings for care quality areas not covered by this report?
- 05How are staff training and competency checks kept up to date?
This was a targeted inspection of infection prevention and control only; the service was inspected but not rated and the other care-quality areas were not assessed. This explanation was written from the published report of 19 November 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 Belvidere Nursing Home Limited
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- April 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Belvidere Nursing Home Limited →
- November 2020Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Belvidere Nursing Home Limited →
- September 2018Goodstayed GoodSafe: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 December 2010.
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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