Belgravia Care Home

Updated 30 June 2022

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

This inspection was carried out by two inspectors.

Belgravia Care Home 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. Belgravia Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

The first day of the inspection was unannounced, the second day was announced.

Inspection activity started on 23 May 2022 and ended 09 June 2022. We visited Belgravia Care Home on 23 May 2022 and 09 June 2022.

What we did before the inspection

What we did before inspection We reviewed information we had received about the service. This included information we had received from the public and notifications sent to us by the provider. This information helps support our inspections. We used all this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We spoke with six people who used the service about their experience of the care provided and three relatives. We spoke with seven members of staff including the owner, registered manager, acting manager, three care staff, the housekeeper and the maintenance person. We reviewed a range of records. This included four people's care records and multiple medication records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 30 June 2022

About the service

Belgravia Care Home is a care home providing personal care to 24 people at the time of the inspection. The service can support up to 25 people with a variety of needs, including people living with dementia and/or mental health challenges.

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

Some areas of the home required cleaning and not all window restrictors met the guidance of the Health and Safety Executive. Audits and checks did not consistently drive improvement.

People’s medicine management required improvement and two care records would have benefitted from more information. We have made a recommendation regarding the safe management of medicines and person centred care records.

People told us they felt safe and they were supported by staff who helped them quickly if they needed this. One person commented, “I don’t need a lot of help but if I do, staff are there for me.” Checks were completed to help ensure prospective staff were suitable to work with vulnerable people. Risk assessments were carried out to help minimise the risk of avoidable harm and staff knew the help and support people needed. A person told us, “I trust the staff, they look after me.”

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 were cared for by staff who were caring, competent and knowledgeable about people's needs. Staff told us training and supervision was arranged to ensure they had the skills to carry out their role. People told us they were happy at the home and they felt cared for. They explained the food was good, enjoyable activities were arranged, and they were supported to access medical advice if they needed this.

People were treated with dignity and respect and staff we spoke with us told us how they respected people and ensured their privacy and dignity was maintained. Care was person centred, met people's needs and expert health advice was sought if this was needed.

Staff told us they felt supported by the management team and they were able to approach them if they needed support and guidance. People told us the management team were approachable and they could talk to them if they wished to.

People were consulted and asked their views on the service provided. Surveys had been completed by people who lived at the home. People told us they were happy at the home and were confident any comments or complaints they made would be listened to.

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

Rating at last inspection and update

This service was registered with us on 15 March 2021 and this is the first comprehensive inspection. We carried out a focused inspection between 11 August 2021 and 16 August 2021 to look at the domains safe and well-led. We did not provide an overall rating for the service.

Why we inspected

This inspection was carried out to check the safety and quality of care people received and provide an overall rating for the 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.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Belgravia Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed. We have identified breaches in relation to the appropriateness of window restrictors and effectiveness of audit system.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.