Belvoir House

Updated 14 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors, a medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Belvoir House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Belvoir House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. Following our last inspection in August 2022 the managing director of the provider had taken over direct management of the service. At the time of the inspection the managing director had submitted an application to register as the manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We observed the care and support people who used the service received. During our visit we spoke with 6 people who used the service, 5 relatives and 10 staff. Staff we spoke with included the deputy manager, the chef, team leaders, and support staff. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We spoke with a further 10 relatives over the phone following our inspection visit. Records were reviewed both on site and remotely and these included the care records for 3 people and medicines records for 10 people. Records relating to the governance were also viewed and included quality assurance audits, staff personnel files, staff training, and health and safety records.

Updated 14 April 2023

About the service

Belvoir House is a residential care home providing personal care to up to 39 people. The service provides support to older people and younger adults, some of whom live with dementia. At the time of our inspection there were 29 people using the service. The home is a converted period building with a large garden. People are accommodated over 2 floors in 2 wings known as Nightingale and Kingfisher, each of which have their own communal areas

People’s experience of using this service and what we found

Improvements had been made in the management of risks to people individually and from the environment. People were supported by enough staff who had been recruited safely. The cleanliness of the service had improved and risks relating to COVID-19, and other infections were assessed and managed. Any safeguarding concerns were identified and responded to appropriately. People received their medicines safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People's needs were considered holistically and nationally recognised tools to assess these were used. Improvements had been made to the training and support provided to staff. This meant people were supported by competent staff. People's meal time experience was improved, people were provided with enough food and drink that met their needs and preferences. People's health care needs were assessed and staff worked with external health professionals to help ensure these were met. The provider had started to undertake a refurbishment programme and improvements had been made to the physical environment.

People and relatives told us the care and support had improved significantly. People were supported by kind attentive staff, who encouraged their independence. People's privacy and dignity was respected and promoted. New systems were in place to ensure people and their relatives were able to express their views on the support they received.

People received person-centred care from staff who knew them well, including their individual needs, social histories, and interests. Care plans contained person-centred information about each person, including people's communication needs. Staff ensured people had the tools and equipment they needed to help them communicate effectively. People and relatives praised the activities now on offer, they were consulted on the activities being offered and this had helped ensure they met people's individual needs and interests. No complaints had been made since the previous inspection, the management team had been open, honest, and reflective in response to the concerns identified at the last inspection.

Changes had been made to the management of the service since the previous inspection. The new management team were responsive, effective, and committed to ensuring improvements to the quality of the service were made. People were supported by staff who understand their responsibilities. Everyone we spoke with told us the service had significantly improved. Relatives praised the homeliness of the service. The culture of the service had changed, staff morale was improved, and the atmosphere was pleasant and welcoming. People and their relatives benefited from a person-centred culture in which staff engaged and listened to them. The management team were open, approachable and supportive. Relationships with the local community had begun to be formed for the benefit of the people using the service. The management team had engaged effectively with other stakeholders who were supporting them to make improvements in the service

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 24 August 2022).

We imposed conditions on the providers registration after the last inspection. This meant the provider had to submit governance documents and assurances every month to CQC.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 25 July 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.