CQC report explained · a residential care home
What the CQC found at Belvoir Vale Care Home
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, safe medicines management, detailed risk assessments and strong infection control.
- Effective?
- Good
- This question was not inspected during this visit. The previous rating was used to calculate the overall rating.
- Caring?
- Outstanding
- People were treated with exceptional kindness, respect and dignity. Staff understood people's individual lives, choices, cultures and needs, and supported them to make decisions.
- Responsive?
- Good
- Care was personalised and regularly reviewed. People were supported with relationships, meaningful activities, communication, complaints and end-of-life wishes.
- Well-led?
- Outstanding
- Inspectors found an exceptionally positive and inclusive culture. Leaders used audits, incident reviews, feedback and partnership working to improve care.
What inspectors found, December 2023
Rated Outstanding overall; inspectors found exceptionally caring and well-led support, with safe and responsive care rated Good.
This was an unannounced focused inspection. Inspectors visited on 17 and 25 October 2023. They spoke with people, relatives, staff and professionals. They also observed care and checked care, medicine, recruitment, incident and management records.
Inspectors found people were safe. There were enough staff, medicines were managed safely, risks were assessed and the home was exceptionally clean. People were treated with exceptional kindness, respect and dignity. Care was highly personal and activities reflected people's interests and relationships.
The service was rated Outstanding overall. Caring and well-led were rated Outstanding. Safe and responsive were rated Good. Effective was not inspected during this visit, so its previous rating was used when calculating the overall rating.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs. Recruitment checks, staff training and medicines systems were in place.
“Staff were recruited safely and there were enough staff deployed to meet people's needs.” from the report
Kind and dignified care
People were treated as individuals and supported with patience, kindness, privacy and dignity.
“People were always treated with the highest level of respect and with their dignity preserved.” from the report
Personalised activities
Staff supported people to follow interests, maintain relationships and achieve personal wishes.
“Activities were truly person centred. Staff supported all people to socialise and take park in activities which were important to them.” from the report
Strong improvement systems
Leaders reviewed incidents, accidents and near misses, and used detailed analysis to reduce risks and improve outcomes.
“The provider had excellent systems and processes in place to continuously improve, develop and monitor the quality of care provided.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and update my relative's care plan when their needs or preferences change?
- 02How many staff will usually be on duty, and how do you make sure this remains enough for the people living here?
- 03How will you support my relative to take part in activities that match their interests and maintain important relationships?
- 04How will you involve my relative and our family in decisions about care, including if they cannot make a decision themselves?
- 05How would you support my relative's wishes, communication needs and dignity at the end of their life?
This was a focused inspection of Safe, Caring, Responsive and Well-led; Effective was not inspected and its previous rating was used to calculate the overall rating. This explanation was written from the published report of 23 December 2023 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, March 2022
Inspected but not rated; inspectors were assured that infection controls were safe and staffing pressures were being managed.
This was an announced, targeted inspection on 1 March 2022. It focused on infection prevention and control during COVID-19, and on whether staffing pressures were affecting care.
Inspectors found supplies of PPE, regular testing, cleaning schedules and safe isolation procedures. They saw that the home was visibly clean and tidy. Visitors could still see people, with extra access for essential care givers.
The provider told inspectors it had measures to manage COVID-19-related staffing pressures. Inspectors were told there were enough staff to support people safely, although non-care staff had sometimes helped care staff during busy periods or staff sickness.
The home was inspected but not rated. This means the visit did not produce an overall quality rating or new ratings for the five key questions.
Infection controls
The home had PPE stations, regular testing, safe isolation arrangements and measures to reduce the spread of infection.
“We were assured that the provider was using PPE effectively and safely.” from the report
Clean environment
Cleaning schedules were in place and the work was checked through regular audits. Inspectors found the home visibly clean and tidy.
“We observed the home was visibly clean and tidy.” from the report
Visiting arrangements
People could have visitors, and essential care givers were given further access to support relatives while risks were considered.
“People had access to visitors when they wanted them.” from the report
Staffing cover
The provider said there were enough staff to cover holidays, sickness and COVID-19 isolation. Agency staff were used when needed.
“There were enough staff to support people safely and to cover any staff holidays, sickness and COVID-19 isolation.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you make sure people receive safe care when non-care staff help care staff during busy periods or sickness?
- 02How many agency staff are currently being used, and how do you make sure they know each person's needs?
- 03How are visiting arrangements managed if there is an infection outbreak or a person needs to isolate?
- 04How often are PPE supplies, cleaning work and infection control audits checked now?
- 05What arrangements are in place if staff are absent because of COVID-19?
This was a targeted inspection of infection prevention and control and staffing pressures; it was not a full inspection and the service was not rated. This explanation was written from the published report of 22 March 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.
Every inspection of Belvoir Vale Care Home
3 rated inspections over 8 years: the service has improved, from Good to Outstanding.
- December 2023Outstandingcurrent ratingSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Outstanding
- March 2022Inspected but not ratedSafe: Inspected but not rated
- December 2020Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodstayed GoodSafe: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- October 2012
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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