Archived: Belvedere Manor

Updated 25 July 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

An unannounced comprehensive inspection took place at Belvedere Manor on 13, 14 and 15 June 2018. The inspection was carried out by two adult social care inspectors, two medicines inspectors, an assistant inspector and expert by experience on the first day, two adult social care inspectors and an assistant inspector on the second day and two adult social care inspectors on the third day. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

In preparation for our visit, we considered the previous inspection report and information that had been sent to us by the local authority’s contract monitoring team. We also checked the information we held about the service and the provider. This included statutory notifications sent to us by the service about incidents and events that had occurred at the home. A notification is information about important events, which the service is required to send us by law.

Prior to the inspection, we received a significant number of concerns about the operation of the service from staff and relatives. Whilst some concerns were being investigated by the local authority’s safeguarding team, we analysed the information and incorporated the themes into the planning of this inspection.

The provider was not asked to submit a Provider Information Return. This is information we ask providers to send us to give some key information about the service, what the service does well and improvements they plan to make.

During our inspection visit, we spent time observing how staff provided support for people to help us better understand their experiences of the care they received. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience people who could not talk to us.

We spoke with 12 people living in the home, ten relatives, five members of staff, the administrator, the chaplain, the chef, the music therapist, the area manager and the registered manager. We also spoke with a visiting healthcare professional and a social care professional.

We had a tour of the premises and looked at a range of documents and written records including a detailed examination of seven people’s care files, seven staff recruitment files and staff training records. We also looked at a sample of people’s medicines administration records, the policies and procedures, complaints records, accident and incident documentation, meeting minutes and records relating to the auditing and monitoring of service provision.

Updated 25 July 2018

We carried out an unannounced inspection at Belvedere Manor on 13, 14 and 15 June 2018.

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 care home is purpose built and accommodates 84 people on three floors known as Village, Woodlands and Garden suite. Woodlands suite specialises in providing care for people living with dementia. At the time of the inspection, there were 71 people accommodated in the home.

The service was managed by a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection carried out on 6, 7, 8 and 13 November 2017, we asked the provider to make improvements to improve the assessment of staffing levels, the management of risks, the management of medicines and the implementation of the Mental Capacity Act. Following the inspection, the provider sent us an action plan and told us they would make the necessary improvements by April 2018.

During this inspection, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 and one breach of the Care Quality Commission (Registration) Regulations 2009. We found continuing shortfalls in the management of medicines, the way risks to people’s health, safety and welfare were managed and the application of the Mental Capacity Act. In addition, we identified further shortfalls in the staff recruitment process and the governance arrangements as well as a failure to submit some statutory notifications.

We are considering what action we will take in relation to these breaches. Full information about the CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

At the last inspection, the service was rated as overall ‘requires improvement’, at this inspection the rating had deteriorated to overall ‘inadequate’.

Safeguarding adults’ procedures were in place and staff spoken with understood how to safeguard people from abuse. However, staff failed to recognise a serious occurrence was a safeguarding incident and delayed completing an incident report. Whilst there was evidence to indicate the circumstances of the incident had been investigated there was no evidence seen to confirm the incident had been reported under safeguarding adults’ procedures.

We saw people’s care files contained individual risk assessments, however, not all risks had been assessed and recorded and consistent action had not always been taken to mitigate risks.

We found serious shortfalls in the recruitment of new staff. Prior to the inspection, we asked for a list of all new members of staff along with details of a specific employment check. The list was confirmed as accurate and correct by the area manager and the registered manager. During the inspection, we found appropriate checks had not been carried out for a member of staff who had been omitted from the list. Whilst the registered manager explained this was an oversight, it meant the information submitted was inaccurate and misleading.

We found dependency profiles had been completed for all people living in the home to help determine the level of staffing. However, people, staff and relatives continued to express concern about the number of staff on duty.

We found there were continued shortfalls in the management of medicines. This included gaps in record keeping and a lack of guidance for staff.

Whilst staff told us they had completed appropriate training, the provider was using four different systems to manage and monitor staff training. This meant we were not able to assess the training completed by staff during the inspection. The registered manager offered to send us an up to date training matrix, however, this was not received. Not all staff had completed induction training when they commenced work in the home and not all staff had received the number of one to one supervisions advised by the provider’s policies and procedures.

The provider was not working within the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) to help ensure people's rights were protected.

Whilst people had access to healthcare services, we found staff had not responded in a timely way to GP advice in respect to one person’s health.

People and relatives told us the staff were caring and kind. However, there was limited evidence to demonstrate people had been involved in the care planning process. This meant people were not given the opportunity to have direct input into the planning of their care.

Each person had an individual care plan, however, we noted some care plans contained conflicting information, which could impact on the delivery of care.

There was a complaints procedure in place and we saw evidence complaints had been investigated and responded to. However, not all complaints had been recorded in a central log, which meant concerns were not considered as whole in order to identify any patterns or trends.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.