CQC report explained · a residential care home
What the CQC found at Belvoir Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, appropriate risk assessments, safe recruitment and safe systems for managing medicines and infection control.
- Effective?
- Good
- People's needs were assessed and reviewed, staff were trained, food and healthcare needs were supported, and the home followed the Mental Capacity Act. The building needed some updates to make it more dementia-friendly.
- Caring?
- Good
- People said staff were kind, patient and respectful. Inspectors saw staff listening to people, protecting their dignity and involving them in decisions.
- Responsive?
- Good
- Care plans were personalised and kept up to date. People had choice over daily routines, communication needs were supported, and activities and relationships were encouraged.
- Well-led?
- Good
- The home had a positive and open culture, regular audits and systems for learning from concerns. Relatives felt able to raise concerns, although some wanted more surveys and questionnaires.
What inspectors found, January 2024
Belvoir Care Home Limited is Rated Good; inspectors found safe, kind and personalised care, but recommended improvements to the building.
This was an unannounced inspection carried out from 9 to 11 January 2024. Inspectors spoke with people living in the home, relatives, staff, managers and health professionals. They observed care and reviewed care, medicines, recruitment, safety and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, personalised care plans, suitable training and good support for people's health, choices, communication and relationships.
The main shortfall was the building. Inspectors found that some repairs and updates were needed, including dementia-friendly signs, contrasting colours in bathrooms, garden repairs and replacement handrails. They made a recommendation, but found no impact of harm at the time of inspection.
Enough staff
Inspectors found staffing levels and skills matched people's needs. People and relatives also said staff were available and familiar.
“There were enough staff to meet people's needs and keep them safe.” from the report
Kind and respectful care
People described staff as caring, patient and compassionate. Inspectors saw staff protect privacy, dignity and personal choice.
“People were treated well and respected and staff had a caring approach towards them.” from the report
Personalised support
Care plans reflected people's needs, interests and wishes. People and relatives were involved in reviewing their care.
“Care plans were personalised and reflected people's needs and aspirations.” from the report
Safe medicines
Staff were trained and assessed as competent to manage medicines. Records, storage, administration and audits were found to be safe.
“The service had systems and processes in place for the safe storage, administration, and use of medicines.” from the report
Activities and relationships
The home offered activities and helped people maintain important relationships. Relatives were welcomed and invited to events.
“People were offered a range of activities and opportunities to socialise by staff.” from the report
Building needs updating
needs fixingInspectors found that some repairs and improvements were needed. Dementia-friendly signs were dated, bathrooms did not always use contrasting colours, and garden repairs and handrail replacement were recommended.
“We recommended the provider consider current guidance on dementia-friendly environments and take action to update the accommodation accordingly.” from the report
More family feedback
minorRelatives felt there could be more surveys and questionnaires to help them give feedback about the home.
“Relatives felt there could be more surveys and questionnaires to help them give feedback.” from the report
- 01What repairs and upgrades to the garden and handrails have been completed since the inspection?
- 02What changes are planned for dementia-friendly signs and contrasting colours in the bathrooms, and when will they be finished?
- 03How will you collect feedback from relatives, including through surveys or questionnaires?
- 04How will you make sure my relative's care plan continues to reflect their choices, interests and changing needs?
This was an unannounced inspection covering all five ratings, including the premises, care, medicines, records, staffing and management systems. This explanation was written from the published report of 25 January 2024 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, April 2021
Belvoir Care Home Limited was inspected but not rated; inspectors found mostly good infection control, with some checks and equipment needing improvement.
This was an announced, targeted inspection on 12 March 2021. It looked at infection prevention and control because of the CQC's response to coronavirus outbreaks in care homes.
Inspectors were assured about visitors, social distancing, admissions, protective equipment, testing, vaccination and managing outbreaks. They also found good communication with families, regular testing and a clean home with good ventilation.
There were two weaknesses. Infection prevention and control audits were not always carried out routinely, and there were not enough foot-operated pedal bins. The provider said these would be put in place, and later confirmed this had happened.
The service was inspected but not rated. This means the report does not give an overall quality rating or full ratings for all five areas of care.
Infection control
Inspectors were assured that the home had effective arrangements for visitors, PPE, testing, admissions and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Clean environment
The home was clean, well ventilated and had invested in air purification.
“The home was clean and hygienic. There was good ventilation within the home and the provider had also invested in an air purifying system.” from the report
Family communication
Families were updated in several ways and were consulted about visiting preferences.
“There were good lines of communication in place, with families being updated by phone, email and videocalls.” from the report
Testing and vaccination
Residents and staff took part in regular COVID-19 testing and the vaccination programme. Risk assessments were completed for people at higher risk.
“Staff and residents were taking part in regular covid 19 testing and the vaccination programme.” from the report
Infection control audits
needs fixingInfection prevention and control audits were not always carried out routinely. The provider said this would be addressed.
“IPC audits were not always routinely taking place and there was a lack of foot operated pedal bins in use.” from the report
Pedal bins
needs fixingThere was a lack of foot-operated pedal bins in use. The provider later confirmed that this would be implemented.
“IPC audits were not always routinely taking place and there was a lack of foot operated pedal bins in use.” from the report
- 01How often are infection prevention and control audits carried out now, and can we see the most recent results?
- 02Have foot-operated pedal bins been provided throughout the home?
- 03How are visitors currently booked and supported to visit safely?
- 04How are residents and staff tested for COVID-19, and how are outbreaks managed?
- 05How will our family receive updates about visiting arrangements or infection risks?
This was a targeted inspection of infection prevention and control practices only; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 1 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.
Every inspection of Belvoir Care Home Limited
3 rated inspections over 8 years: the service has held its Good rating throughout.
- January 2024Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021Inspected but not ratedSafe: Inspected but not rated
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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