The Belfry Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last inspection we found the provider to be in breach of legal requirements relating to risk management, staffing and safe medicines management. At this assessment, the provider has made enough improvement in relation to identifying and assessing risks to people, ensuring enough suitably qualified, competent and experienced staff and safe medicines management and was no longer in breach of these legal requirements. We reviewed 6 quality statements under this key question; Learning culture, Safeguarding, involving people to manage risk, Safe and effective staffing, Infection prevention and control and Medicines optimisation. At this assessment we found a positive culture of safety based on openness and transparency. Although concerns about safety were listened to and investigated, they were not always reported where required. The service used a lesson learned approach to share information to improve the quality of the service to people and staff. Staff had been recruited safely and there were enough suitably trained staff to meet people’s needs. People received their medicines by staff who were trained to do so, however we did find the provider had not undertaken their own medicine competency assessments for agency staff who regularly worked the night duty shift, relying on the agency’s training. Following the assessment the provider immediately completed competency assessments with the agency staff identified for their own assurances. When carrying out checks of the medicines room storage areas we found some out of date dressings which had not been disposed of and medicine pots used to administer people’s medicines stored inappropriately. The registered manager rectified this during our visit. Care plans contained risk information relating to individual people’s needs. Infection prevention and control measures were in place and the provider had a service improvement plan underway to update some areas of the home.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives spoke highly of the service and the care they received. A person told us, “I know [name of manager] I can raise any day to day issues if I was not happy. They [managers] are always here, it takes a lot of initiative to manage this place well, I would not change anything.” A relative told us, “It is very well run, they keep me well informed, they call me and discuss any issues.”

Systems and processes were in place to support continued learning. These included supervisions, training, investigations of concerns and the completion of logs for incidents, accidents, potential safeguarding events and complaints. The service had a low level of complaints, and we could see immediate action had been taken to resolve any issues raised.

Staff told us when incidents had occurred, these were used as a discussion point in 1:1 supervision, staff meetings. A member of staff told us, “We have a lot of staff meetings and go through anything. The management are always talking to us.” The registered manager told us, “We encourage staff to speak up about anything. We have a private work group chat; we hold staff meetings and incorporate 3 handovers daily to ensure information is shared amongst the team.”

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff had received training in how to safeguard people and knew how to raise any concerns with the management and how to report concerns externally if required. A member of staff said, “I would speak to the managers, I would also report to CQC as whistleblowing allows us to speak out openly, I have completed the online training.” Another member of staff said, “If someone was distressed. I would report this direct to the senior who would then contact the manager. If I were not happy, I would go to CQC.”

Safeguarding policies were in place. The registered manager had reported some concerns to the relevant safeguarding agency and the Care Quality Commission, but not all. The registered manager was now aware moving forward of the need to notify the local authority and CQC of all unwitnessed falls and skin tear-related injuries as this had also been highlighted during a recent visit from the local authority.

People told us they felt safe. One person said, “I feel safe here. I am unable to get out for my own safety. I have a call bell if I press it the staff will come and attend to me.” Another person said, “The staff are attentive, especially if I need help during the night, I feel safe here.”

Staff knew people well and told us information regarding risks to people was recorded within their care plans. A staff member told us, “All risks are recorded on the care plan. We have handover on each shift so any changes we are kept updated about, we also have a group chat.” Another member of staff told us, “The senior tells us about any risk, everybody hears everything here and we communicate well, and everyone is kept informed.”

People told us they were involved in planning their care and managing risks. Care plans and risks assessments included information on how to support people safely. One person said, “They know how to look after me, I had a few falls prior to coming here, I only have to move a bit and they see me and make sure I have my walking frame to hand."

During our assessment, we observed safe manual handling practices among staff. For example, a member of staff was assisting a person back to their bedroom, the member of staff was kind, patient and prompted the person on how to correctly position themselves in front of their armchair with their frame, turn it around and shuffle backwards until they were able to feel their chair at the back of legs. The member of staff prompted the person to feel for the arm of their chair for support and they were then able to lower themselves safely until seated.

Risks to people’s health and wellbeing had been identified, assessed, reviewed regularly, and updated when required. Although we did find where a person was diabetic there wasn’t any guidance for staff in relation to what to do in the event of the person having a hypoglycaemic/hyperglycaemic attack. This is where a person’s blood glucose levels either drop too low or are too high. Following the site visit the registered manager advised they have sent the relevant diabetes risk assessments and blood glucose readings to the diabetes nurse for review and advice.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

On the day of our assessment, there was enough staff present to support people safely. The communal lounge had a member of staff present to attend to people’s care and support needs. Due to the size of the service staff duties included housekeeping duties, laundry and cooking. However, this did not appear to impact on the time spent with people.

People and relatives told us they were satisfied with the staffing levels within the home. One person told us, “The staffing levels are generally good here, it’s the same at the weekend.” A relative told us, “There is a good staff ratio, so people here get a lot of attention.”

The staff we spoke with were positive about working at the service and told us there were enough staff. A staff member told us,” We could always do with an extra pair of hands, if someone goes sick, we try to cover or get agency. Staff will work extra hours to cover.” Another member of staff told us, “The staff are always about and there is enough staff to look after people.”

Systems were in place to ensure there were enough suitably qualified, skilled and experienced staff. Safe recruitment practices were followed. We checked the recruitment records for 3 members of staff and all the required pre-employment checks had been completed. This included disclosure and barring service (DBS) checks and obtaining up-to-date references. The registered manager told us they used longstanding agency staff to cover the night shifts at the service who had been with them for years. When we checked the agency induction profiles, we found some were out of date and did not reflect if their training was current and up to date. Following the site visit the registered manager advised they had received updated profiles for all current agency staff and undertaken all agency night care workers medication competencies. In addition, they had set up an agency staff matrix to alert them when updates are needed.

The provider had infection prevention and control policies and procedures in place, staff had undertaken infection prevention and control training. Although some areas of the home and some equipment like lap tables required replacing/updating, the registered manager provided us with their service improvement plan which identified works planned and timescales of commencement.

The home was clean and hygienic on the day of our assessment. People’s bedrooms, communal areas and bathrooms were free of malodours.

The provider’s medicine policies and procedures were in place and regular audits were carried out; however, we did find the most recent audits had not identified some of the minor concerns we found on the day of our assessment. We found in the medicines room that old dressings supplied for people’s wound care had expired and medicine pots with sticky liquid residue in a basket with pens/scissors/unused urine sample bottles. Although the registered manager responded immediately and took action to clean and dispose of the above and went on to order disposable medicine pots for single use only, moving forward more time is required to demonstrate sustained oversight.

People told us they received their medicines, one person told us, “Yes, I always get them on time,” Another person told us, “The staff are trained to give me my medicines, I always get them on time.”

Staff told us they had undertaken medicines training, although it was the senior care staff who administered people’s medicines. A member of senior care staff told us, “I do administer medicines and have completed the training and have my competency checked. I have also completed a [medication] course.”