CQC report explained · a residential care home
What the CQC found at 2 Belgrave Terrace
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Most risks were managed, and medicines and staffing arrangements were safe. However, some personal risk information was not prominent enough, some evacuation plans needed more regular review, and the building had trip hazards and missing call bells in two ground-floor bedrooms.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff had relevant training and supervision, and people received support with food, healthcare, choice and decision-making.
- Caring?
- Good
- Staff were kind, respectful and familiar with people's preferences. People were supported to be independent, make choices and stay involved with family and advocacy.
- Responsive?
- Good
- Care plans covered people's physical, emotional, psychological and social needs. People were supported with communication, family relationships, hobbies, community activities, work placements and day services.
- Well-led?
- Good
- The manager was described as approachable and audits, meetings and feedback systems were in place. Some improvements were needed to environmental audits and to recording informal complaints.
What inspectors found, December 2019
Rated Good overall; inspectors found kind, personalised care, but safety needed improvement.
This was an unannounced inspection on 26 November 2019. The inspector spoke with all six people living at the home, one relative and five staff. They reviewed care plans, medicine records, staff files and management records.
People were described as safe, cared for kindly and supported to make choices. Staff knew people well. People were supported with meals, healthcare, activities, community visits, work placements and holidays.
The overall rating was Good. Effective, Caring, Responsive and Well-led were all rated Good. Safe was rated Requires Improvement because some risks, building issues and care record information needed improving. The provider sent an action plan immediately after the inspection for several issues.
Kind and respectful staff
Inspectors found that staff had good relationships with people and treated them with dignity. People and relatives said staff were kind and supportive.
“Staff had developed good relationships with people, were caring in their approach and treated people with respect.” from the report
Choice and independence
People were involved in decisions about their care and daily lives. Staff supported them to develop skills and do more for themselves.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Active lives
People were supported to keep in touch with family and take part in hobbies, community activities, work placements, day services and holidays.
“They went shopping, swimming, for meals out and cinema trips, to concerts, discos, socialised with people in other homes and went on holidays and day trips.” from the report
Staff training and support
Staff received induction, ongoing training and supervision. They were trained before giving medicines and had regular checks of their competence.
“Staff did not administer medicines until they had been trained to do so.” from the report
People's involvement
People and relatives were involved in care planning and decision-making. Information was provided in symbol and pictorial formats for people who might not read.
“Information such as menus, activities and some policies such as complaints, fire awareness and health and safety were available in symbol and pictorial format for people who may not read.” from the report
Building safety
seriousInspectors found stone steps without external lights, trailing wires and no nurse call bell in two ground-floor bedrooms. The provider said these issues were being addressed after the inspection.
“The two bedrooms on the ground floor did not have a nurse call bell to alert staff, including overnight staff who slept on the third floor, if people were unwell or needed assistance.” from the report
Risk information
needs fixingSome personal evacuation plans needed more regular review. Guidance about choking and distressed behaviour, including possible triggers and ways to reduce distress, was not always clear enough in care plans.
“Information about the management of risks to people such as for choking or distressed behaviours should also feature more prominently within people's care records to ensure all staff were aware of how to manage the risk.” from the report
Confidential records
needs fixingSome care records were kept in the kitchen rather than securely. This was addressed during the inspection.
“Some care records were accessible in the kitchen and were not stored securely to respect people's confidentiality.” from the report
Informal complaints
minorThe manager was asked to keep a separate record of informal concerns, including concerns raised by people using the home, to protect privacy.
“We discussed that a separate log could be kept of informal concerns that were raised including those raised by people who used the service, to maintain people's privacy.” from the report
- 01Have the trip hazards, external lighting and missing nurse call bells identified at the inspection now been fixed?
- 02How often are personal emergency evacuation plans reviewed when people's needs change?
- 03How are choking risks and distressed behaviour triggers and de-escalation guidance shown clearly in each person's care plan?
- 04Where are care records stored now, and how is confidentiality checked?
- 05How are informal complaints and concerns recorded, reviewed and acted on?
This was an unannounced inspection of the care, premises and management of the home, covering all five CQC questions. This explanation was written from the published report of 21 December 2019 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, June 2017
Potensial Limited - 2 Belgrave Terrace was rated Good; inspectors found caring, safe support with some records and medicines details needing improvement.
The inspection took place on 9 and 16 May 2017. The first visit was unannounced. A second visit was arranged because the registered manager was not available on the first day. Inspectors spoke with all seven people living at the home, one relative and several staff. They reviewed care, medicine and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were safe, staff were trained, healthcare needs were supported and care was personalised. They saw warm and respectful relationships, with people involved in choices about food, activities and daily life.
There were some areas to improve. These included more detailed instructions for some medicines, reviews of mental capacity records, missed staff supervisions and duplicated paperwork during the move to a new electronic system. The home had identified these issues in its action plan.
Kind relationships
Inspectors saw staff treating people with warmth, respect and dignity. People appeared comfortable, happy to joke and able to ask staff for support.
“We observed warm, caring and dignified relationships between people and staff.” from the report
Personalised support
Care plans covered people's communication, health, daily support and community activities. People were involved in decisions about food, outings and how they spent their time.
“Care plans contained detail information on what people would like help with, who they would like to help them, when they would like help and how they would like to be assisted.” from the report
Trained staff
Staff training was up to date and included areas linked to the needs of people at the home, such as autism, diabetes and behaviours that challenge.
“Training was up to date and staff had completed eLearning, i.e., computer based, training in safeguarding, administration of medicines, first aid, fire awareness, equality and diversity, health action plans, person centred planning, mental capacity and DoLS.” from the report
Choice and activity
People chose activities including going to the gym, walking, shopping, attending groups and voluntary work. Residents' meetings were led by the people using the home.
“People had some access to day service facilities, but when they were at home people continued to choose their own activities.” from the report
Quality monitoring
The registered manager and regional director completed audits. The home used action plans to track improvements and responsibilities.
“A range of quality assurance and governance systems were in place.” from the report
As-needed medicines
needs fixingThe plan for one as-needed medicine did not explain clearly enough how long to wait between doses or what other strategies to try first. The manager said a detailed plan would be written that day.
“The administration plan for this medicine lacked some detail in relation to timing between administrations and strategies to use before administering the medicines.” from the report
Capacity records
needs fixingSome DoLS screening and consent records had not been reviewed regularly. One screening record was dated July 2013.
“We saw DoLS screening tools were in place to assess capacity; however these had not been routinely reviewed.” from the report
Staff supervision
needs fixingSome planned staff supervision meetings were missed during 2016 and early 2017. The report says this had been identified for improvement.
“The supervision schedules evidenced some staff supervisions had been missed during 2016 and so far during 2017 staff had attended supervision meetings on a quarterly basis.” from the report
Record duplication
minorCare records contained duplicated and archived information while the home moved to a new electronic system. Staff said there was too much paperwork.
“There is a significant amount of documents in support plans [often duplicated] and staff appear to be completing documentation at least twice.” from the report
Computer access
minorStaff said the computer system was not always accessible. The home had a handwritten backup process, but records might have to be added later.
“On day one of inspection the system was not accessible.” from the report
- 01Has the detailed protocol for the as-needed medicine been completed, including the timing between doses and alternatives to try first?
- 02Have all DoLS screening tools and capacity-to-consent records been reviewed and updated?
- 03Are staff now receiving supervision at the planned frequency?
- 04Has the move to the Caresys electronic system been completed, and has duplicated paperwork been reduced?
- 05What happens when the computer system is unavailable, and how are handwritten records checked and added later?
This inspection covered the overall service and all five CQC questions, using observations, discussions and reviews of care, medicine, staffing and management records. This explanation was written from the published report of 21 June 2017 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 2 Belgrave Terrace
3 rated inspections over 5 years: the service has held its Good rating throughout.
- December 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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39 live-in carers within about an hour of South Tyneside
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Most charge £950 to £1,140 a week. 34 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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