CQC report explained · a nursing home
What the CQC found at The Belvedere
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that risks and medicines were generally managed well, but some environmental checks were overdue. They also found problems with PPE disposal and the recording of bedroom and mattress checks.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- There was no registered manager, and governance systems were being redesigned. Inspectors found some inaccurate records and noted limited activities and task-focused care.
What inspectors found, October 2021
Rated Requires Improvement; inspectors found kind care and safe medicines management, but gaps in safety checks, records and management oversight.
This was an unannounced focused inspection on 3 and 14 September 2021. Inspectors looked only at Safe and Well-led because the inspection was prompted by concerns about medicines, staffing and management. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
People and relatives were generally positive about the care. Inspectors found enough staff for people's care needs, safe recruitment, suitable medicines training and accurate medicines records. Risks were usually assessed and managed, and people were supported by kind and caring staff.
There were important weaknesses. Some environmental safety checks were overdue. Inspectors found incorrect or late records of bedroom checks and mattress settings. The home also had no registered manager, limited activities, and some concerns about cleanliness, PPE disposal and staff support during meals.
The overall rating fell from Good at the previous inspection to Requires Improvement. This means the home was not consistently safe or well-led, and improvements were needed. The other three question ratings were not inspected during this visit and were carried over from the earlier comprehensive inspection.
Risk planning
Most risks to people's safety were assessed, recorded in support plans and acted on by staff.
“Risks to people's safety were assessed and detailed information was recorded in their support plans to manage any identified risk.” from the report
Medicines
People received medicines as prescribed. Staff had suitable training and their competence was checked.
“People received their medicines as prescribed and staff kept accurate medicines records.” from the report
Kind staff
People and relatives generally said they felt safe and received kind care.
“People and their relatives indicated people felt safe living at The Belvedere and were supported by kind and caring staff.” from the report
Staff recruitment
The staff checked before employment included criminal record checks and references from previous employers.
“Staff had been safely recruited. Staff had pre-employment checks to check their suitability before they started working with people.” from the report
Overdue safety checks
needs fixingSome environmental safety and maintenance checks had not been completed on time. The report says these were in progress during the inspection.
“Some environmental safety and maintenance checks were overdue.” from the report
Inaccurate records
seriousTwo bedroom checks were recorded late, and two mattress-setting records said checks had been completed when the settings were incorrect. This reduced assurance that people were being checked properly.
“We also found two records completed to indicate mattress settings had been checked, but these were incorrect.” from the report
Infection control gaps
needs fixingA toilet and other surfaces were not visibly clean on the first inspection day. PPE was also not always disposed of correctly or removed before leaving a bedroom.
“However, PPE had not been disposed of correctly in one area and a staff member had not removed their PPE before leaving a bedroom.” from the report
Management uncertainty
needs fixingThere was no registered manager. A new manager had been recruited but had not yet applied to register, while other management roles were also being recruited.
“There was no current registered manager in post.” from the report
Limited activities
minorThe home was quiet during the inspection, with little activity taking place. The provider planned to improve lifestyle support and meaningful activities.
“During the inspection the home was quiet with little activity taking place.” from the report
- 01Have all overdue environmental safety and maintenance checks now been completed, and how are they monitored?
- 02How do you make sure bedroom checks are recorded at the time they happen and mattress settings are recorded accurately?
- 03Who is currently responsible for managing the home, and has the new manager applied to register with CQC?
- 04What has changed to improve meaningful activities and indoor activities for people living with dementia?
- 05What has changed to improve cleanliness, PPE disposal and support during meals?
This was an unannounced focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 7 October 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.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and personalised care, with some recording inconsistencies corrected during the inspection.
This was an unannounced inspection on 24 and 29 January 2020. The inspector spoke with people living in the home, relatives, staff and visiting professionals. They also observed care and checked care, medicine, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines management, clean surroundings and suitable care plans. People were treated with kindness and respect, and staff knew their needs and preferences.
Care plans had improved since the previous inspection. Inspectors found that some monitoring records were inconsistent, but the manager acted during the visit and improved the recording systems. The previous overall rating was also Good, while Responsive had improved from Requires Improvement to Good.
Enough trained staff
Inspectors found enough suitably skilled and experienced staff to meet people's needs safely. Relatives also said the home was not short staffed.
“There were enough suitably, skilled and experienced staff on duty to safely meet people's needs.” from the report
Personalised care
Care plans reflected people's individual needs, histories and preferences. Staff knew people's likes and dislikes and used this knowledge in their care.
“Care plans had been improved since our last inspection. They were personalised and reflected people's individual needs, history and preferences.” from the report
Kind and respectful care
Staff promoted people's choice, privacy, dignity and independence. Inspectors found that staff had developed good relationships with people.
“Staff knew people well and had developed good relationships with them.” from the report
Activities and social life
People were offered group and individual activities, with support for hobbies, exercise and social interaction. Relatives were welcomed into the home.
“We could see that people thoroughly enjoyed the activities on offer which stimulated social interaction and provided opportunity for physical exercise.” from the report
Quality oversight
Managers used systems to check the quality and safety of the service and shared learning when things went wrong. Staff said they felt supported.
“Effective systems for checking on the quality and safety of the service and for making improvements were in place and were being followed.” from the report
Inconsistent monitoring records
needs fixingSome care monitoring charts were not recorded consistently. The manager responded during the inspection and improved the recording systems, but families should check that this remains reliable.
“We found some inconsistences in what staff were recording. However, the manager responded effectively, and recording systems were improved during the inspection.” from the report
- 01What checks are now used to make sure care monitoring charts are completed consistently?
- 02Can you show how my relative's care plan reflects their current needs, history and preferences?
- 03How will you involve me and my relative in care plan reviews and decisions about care?
- 04What activities are available for people who prefer individual support or have particular hobbies?
- 05How would you support my relative to record and follow their end of life wishes?
This was an unannounced planned inspection covering all five CQC questions, including both the care provided and the care home environment. This explanation was written from the published report of 13 March 2020 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 Belvedere
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2020Goodstayed GoodSafe: GoodWell-led: Good
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 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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