CQC report explained · a residential care home
What the CQC found at Belvidere Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always available, given as prescribed or recorded clearly. Risk assessments, safeguarding procedures, fire-safety actions and some recruitment checks also needed improvement.
- Effective?
- Requires improvement
- Some DoLS applications were delayed, healthcare needs were not always addressed promptly, and training did not always provide enough depth for complex needs. The environment was not always dementia friendly.
- Caring?
- Good
- This key question was not inspected during this focused visit. The report says people and relatives were happy with the care and that people were treated with respect.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The report says systems supported people to maintain contact with loved ones and relatives were kept informed.
- Well-led?
- Requires improvement
- Audits and governance systems did not identify or correct important shortfalls. The manager was described as open and receptive to feedback, and had begun taking corrective action.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found important problems with medicines, risk management and oversight, although improvements had started.
This was an unannounced focused inspection. Inspectors visited on 10 and 15 March 2022, spoke with people, relatives and staff, and checked care records, medicine records, recruitment files and management records.
They found that medicines were not always given as prescribed or recorded properly. Risks were not always assessed or managed, some safeguarding incidents had not been reported, and some recruitment checks were incomplete. Infection control arrangements gave inspectors only some assurance.
People's healthcare needs were not always dealt with quickly. Staff had training, but some essential training was incomplete and more in-depth training was needed for complex needs. The home also needed improvements to its dementia-friendly design and signage.
The home was rated Requires Improvement overall, and for Safe, Effective and Well-led. Caring and Responsive were not inspected in this focused visit, so their previous ratings were carried forward. The previous overall rating was Good, published in November 2018.
People felt safe and cared for
People and relatives told inspectors they were happy with the care. People said staff met their needs and treated them respectfully.
“People told us they felt safe when supported by staff.” from the report
Open management
The manager acted immediately when inspectors raised concerns and was described as approachable, honest and willing to improve the home.
“Throughout the inspection we found the registered manager to be honest, open and transparent about any issues we brought to their attention.” from the report
Family contact
The home supported relatives to keep in touch during the COVID-19 pandemic through visits, video calls and telephone contact.
“Systems were in place to support people to maintain contact with their loved ones.” from the report
Personalised rooms
People's rooms reflected their personal interests and belongings. Equipment was also available to support independence.
“People's rooms were personalised with pictures and ornaments that reflected the person.” from the report
Missed and poorly recorded medicines
seriousTwo people ran out of medicines. One person went without medicines for 17 days and another for three days. Other medicine records were incomplete or unclear.
“We found two people had ran out of their medicines which placed them at risk of harm.” from the report
Risks were not consistently managed
seriousSome risks, including use of stairs, movement around the lift and fire-safety issues, had not been properly assessed or dealt with. Accident records were not analysed for patterns or learning.
“Risks to people had not always been assessed and mitigated to reduce the risk of harm.” from the report
Weak oversight and audits
seriousThe home's audits failed to identify several problems with medicines, risk assessments, monitoring records, reporting and recruitment checks. This led to a breach of good governance requirements.
“Systems and processes were ineffective and not robust enough to maintain oversight of the service.” from the report
Healthcare follow-up
needs fixingRecords did not always show that refused oral care had been escalated. Inspectors also found that action had not been taken promptly when one person had a sore eye.
“We observed one person to have a sore eye, but no action had been taken to address this until we raised this with staff.” from the report
- 01What changes have you made to prevent medicines running out, and how do you now check that every dose is given and recorded correctly?
- 02How are risks such as stairs, lift access, falls and fire safety assessed and reviewed for each person?
- 03How do you make sure safeguarding incidents are reported promptly to the local authority and CQC?
- 04What essential and specialist training have staff completed since the inspection, particularly for people with complex needs or distressed behaviour?
- 05What improvements have been made to signs, bedrooms, communal areas and access to the garden for people living with dementia or mobility difficulties?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 10 May 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, January 2021
Inspected but not rated; inspectors were assured that infection prevention and control arrangements were safe during a COVID-19 outbreak.
This was an announced, targeted inspection on 17 December 2020. Inspectors checked infection prevention and control arrangements because the home had a COVID-19 outbreak.
Inspectors found clear zoning and separation arrangements. They saw appropriate personal protective equipment being used and were assured about testing, cleaning, social distancing, admissions and outbreak management.
Visits were not taking place at the time because of the outbreak. The home had plans for restarting visits, including testing visitors and using protective equipment.
The service was inspected but not rated. This means the inspection did not give an overall quality rating or a rated judgement on the full range of care.
Infection control layout
The home used clear zones and separate areas to reduce infection spread. A second lounge was used to support people safely during the outbreak.
“The home had clear zoning and cohorting procedures in place to reduce the spread of infection.” from the report
Protective equipment
Staff were seen wearing suitable protective equipment, and equipment stations were available in important areas of the home.
“Staff were observed wearing appropriate PPE in line with current government guidance.” from the report
Visitor planning
Although visits were stopped during the outbreak, the home had a plan for restarting them, including visitor testing and protective equipment.
“The provider had a clear plan in place when visits could safely resume which included visitors taking the lateral flow test for COVID-19 prior to their visit and wearing Personal Protective Equipment (PPE).” from the report
Support for staff
The provider offered wellbeing support and incentives to staff who needed to isolate.
“The provider supported staff wellbeing through incentives and support when they were required to isolate.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current visiting arrangements, and what happens if there is an infection outbreak?
- 02How are visitors tested and supported to use protective equipment?
- 03How would you safely support a person living with dementia or at risk of falls during an outbreak?
- 04How often are staff and residents tested when there is an outbreak?
- 05What infection control arrangements are in place for new admissions?
This was a targeted inspection of infection prevention and control during a COVID-19 outbreak; it did not rate the other areas of care or the service overall. This explanation was written from the published report of 1 January 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 Belvidere Residential Care Home
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Belvidere Residential Care Home →
- January 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Belvidere Residential Care Home →
- November 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- June 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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