CQC report explained · a residential care home
What the CQC found at The Belfry Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2022
The Belfry Residential Home was rated Requires Improvement; inspectors found risks with medicines, staffing, care records and management oversight.
This was an unannounced focused inspection on 17 November and 15 December 2021. Inspectors spoke with one person, two relatives, five staff members and one health professional. They observed care and reviewed care, medicine, staff and management records.
The home was not always safe or effective. Risk assessments and care plans were sometimes inaccurate or contradictory. Medicines were not always managed safely. Staffing levels were not reliably calculated, and one person waited 20 minutes for help to use the bathroom.
Care was not always personalised. Inspectors found limited social interaction and little evidence that people were supported with pastimes they chose. Staff generally knew people well, relatives spoke positively about staff, and infection control, cleanliness, family visits and complaints handling were described positively.
The overall rating fell from Good at the previous inspection, published in April 2018, to Requires Improvement. The report says the provider must make improvements and that CQC will ask for an action plan, monitor progress and return to inspect again.
Infection control
Inspectors were assured that the home had safe infection prevention and control arrangements, including the use of protective equipment and support for visits.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Clean and homely setting
The home was described as environmentally clean and homely.
“The provider had safe infection prevention and control processes in place and the service was environmentally clean and homely.” from the report
Positive relationships with health professionals
The home worked with health professionals, including speech and language and dementia services, to support people's health needs.
“The provider had developed positive working relationships with other health professionals in order to improve people's care.” from the report
Medicine safety
seriousMedicine stock errors had not been found by the home's audit. Some medicines were not labelled accurately after opening, and instructions for as-required medicines were not always up to date.
“People's medicines were not always safely managed, and the provider's medicines audits had failed to highlight the errors found on inspection.” from the report
Staffing levels
seriousThe home could not show that it had enough suitably skilled staff at all times. One person waited 20 minutes for bathroom support because two staff were needed and only one was available.
“We could not be assured there were enough suitably qualified, competent and experienced staff to support people's needs.” from the report
Care records and risk assessments
seriousRecords did not always reflect people's current needs and sometimes gave contradictory instructions about mobility, continence, diabetes, eating and drinking or personal care.
“People's care plans and risk assessments did not always reflect their current needs and contained contradictory information about how to support them.” from the report
Staff training
needs fixingInduction was not always comprehensive. Some training was incomplete or out of date, including training about people's specific health needs.
“The provider had not ensured staff training was renewed in line with best practice and staff had not always received training to support them to understand people's specific health needs such as diabetes and pressure care.” from the report
Social activities and personalisation
needs fixingStaff were often occupied with physical care, leaving limited time for conversation or activities. The home could not show that people were supported with meaningful pastimes of their choice.
“The provider was not able to demonstrate how people were being supported to engage in meaningful pastimes of their choice.” from the report
Management checks
seriousQuality checks did not identify the problems found by inspectors, including concerns about records, medicines, staffing, activities and training.
“The provider's processes for monitoring the quality and safety of the service were not robust and had failed to identify the concerns we found during the inspection.” from the report
- 01What changes have you made to prevent medicine stock, labelling and as-required medicine errors?
- 02How do you calculate staffing levels at times when people need two staff for personal care?
- 03How do you make sure every care plan and risk assessment is current, accurate and consistent?
- 04What activities are now available, and how do you record each person's interests and choices?
- 05Which staff training and induction requirements were outstanding, and how do you check they are now complete and up to date?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and the previous rating for that question was carried forward. This explanation was written from the published report of 12 January 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, May 2021
Inspected but not rated; inspectors found good infection prevention arrangements, but this visit did not provide an overall quality rating.
This was an announced, targeted inspection on 13 April 2021. It looked at infection prevention and control because of the coronavirus pandemic.
Inspectors were assured that the home was using PPE safely, following testing guidance and managing visitors, admissions, shielding and social distancing. The home was visibly clean and had cleaning schedules, audits and practice checks.
People were supported to keep in contact with family and friends. Staff had infection prevention training and management support. The inspectors also signposted the provider to resources to develop its approach.
The home was inspected but not rated. This report does not give an overall rating or ratings for the other areas of care.
Infection prevention
Inspectors were assured that the home had arrangements to reduce the risk of infection and manage possible outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
PPE and staff training
Staff had infection prevention training, and PPE was available and accessible for use.
“Staff employed at the service had received training on infection prevention and the correct use of personal protective equipment (PPE).” from the report
Clean premises
The home was visibly clean and had schedules showing that regular cleaning took place.
“The service was well maintained and visibly clean. Schedules were in place to show that regular cleaning was undertaken.” from the report
Family contact
Contact with family and friends was being supported, which inspectors said benefited people's mental health.
“The benefits of these visits helped people's mental health.” from the report
Further development identified
minorInspectors signposted the provider to resources to develop its approach. The report does not explain what specific changes were needed.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What changes have you made after inspectors signposted you to resources to develop your infection prevention approach?
- 02How do you currently manage visits from family and friends while reducing infection risks?
- 03How often are cleaning checks, audits and observations of practice completed, and what happens if they identify a problem?
- 04How are people and staff tested for infections, and how would you manage an outbreak?
- 05How do you make sure staff continue to use PPE correctly and safely?
This was a targeted inspection of infection prevention and control under the Safe question only; it was not a full inspection and the service was not rated. This explanation was written from the published report of 18 May 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 The Belfry Residential Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- January 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2021Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodup from Requires improvementSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 November 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
35 live-in carers within about an hour of Essex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 25 can care for a couple. 10 years' experience on average.
“Not only was she professional, polite and efficient but she bought a lovely smile and laughter to my parents home.”
“She brought fun and stimulation into mums life.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.