Background to this inspection
Updated
27 October 2021
The inspection
This was a targeted inspection to check whether the provider had met the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 following receipt of concerns about the infection prevention and control practices and the management of medicines.
As part of this inspection, we also looked at the infection control and prevention measures to 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 one inspector.
Service and service type
Belvedere Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided. The previous registered manager left the service in July 2021 and the new manager was appointed in September 2021. The manager told us they had begun the application process.
Notice of inspection
The inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service, such as notifications. These are events that happen in the service that the provider is required to tell us about. We also sought feedback from the local authority.
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
We spoke with three people living in the home, three members of staff, the deputy manager and the manager. We also looked around the premises with the manager.
We observed staff interactions with people and reviewed a range of records, this included seven people's medication records. We also reviewed a variety of records relating to the management of medicines and infection prevention and control.
After the inspection
We continued to seek clarification from the manager to validate evidence found.
Updated
27 October 2021
About the service
Belvedere Manor provides accommodation and personal care for up to 84 people. The home is a purpose built property situated in Colne. The home has three floors known as Village suite, Woodlands suite and Garden suite. Woodlands suite specialises in providing care for people living with dementia. At the time of the inspection, there were 56 people accommodated in the home.
People’s experience of using this service and what we found
People told us they felt safe and staff were kind and caring. Staff understood how to safeguard people from abuse and report any concerns. There were sufficient numbers of staff deployed to meet people's needs and ensure their safety. Appropriate recruitment procedures ensured prospective staff were suitable to work in the home. People received their medicines safely and on time. Risk assessments were carried out to enable people to retain their independence and receive care with minimum risk to themselves or others. People were protected from the risks associated with the spread of infection.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People’s needs were assessed prior to them using the service. There was ongoing training for all staff. Staff were supported with regular supervisions and were given the opportunity to attend regular meetings to ensure they could deliver care effectively. People were supported to eat a nutritionally balanced diet and to maintain their health.
Staff treated people with kindness and respect and spent time getting to know them and their specific needs and wishes. Our observations during the inspection, were of positive interactions between staff and people who lived in the home. Staff were responsive to people’s needs.
People were provided with appropriate activities and had access to a complaints procedure. All people had a care plan which was reviewed at regular intervals.
The registered manager carried out a number of audits to check the quality of the service. The registered manager provided clear leadership and took into account the views of people, their relatives, staff and visiting professional staff about the quality of care provided. The registered manager and staff used the feedback to make ongoing improvements to 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
The provider was registered with us on 12 December 2018 and this is the first inspection.
Why we inspected
This was the first inspection of the service based on the registration of the home.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.