Belmont House Care 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

Our rating for this key question remains requires improvement. People remained at risk of avoidable harm. The provider had not robustly reviewed care plans and risk assessments and kept these updated. We observed some risks in the environment. People did not always receive their medicines as prescribed. We received mixed feedback about staffing levels. However, people told us they felt safe. Recruitment processes were robust. Staff were trained to meet people’s needs. Staff were knowledgeable about safeguarding. Safeguarding procedures were in place and the registered manager had good oversight of accidents and incidents. Processes were in place to ensure appropriate referrals were made to external professionals when needed. Systems were in place to allow visitor access, while ensuring people’s safety. The home and people’s rooms were clean and well-maintained. The provider was responsive to our feedback and sought to resolve the issues we identified as soon as possible.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We could not be assured people were safe from avoidable harm. The provider had not always robustly reviewed and accurately updated people’s care records following a safety incident to prevent recurrence. However, staff supported people to raise any concerns they may have around safety. People knew who the registered manager was. They were confident any issues would be resolved. One person said, “I know I could speak to the manager, [name], and I think [they] would do [their] best to sort it out.”

Most staff told us any learning and best practice following incidents was shared with them. Some staff said they didn’t hear about the outcomes of safety incidents and didn’t have best practice advice shared with them. Staff and audit processes had not identified inconsistent and inaccurate recording of information in some people’s care records which indicated there may be gaps in staff knowledge. However, staff knew the process to report issues, and they were supported to raise any concerns. Staff told us accidents and incidents were investigated thoroughly. One said, “[Registered manager] is very thorough with investigations.” Another said, “[Registered manager] is prompt, honest, and decisive in [their] approach. [Registered manager] listens carefully, understands staff concerns, thoroughly assesses and investigates issues rather than relying on hearsay.”

The systems in place to identify and manage risk had not always worked effectively. For example, some people’s care records contained conflicting information and insufficient detail for staff around control measures relating to a known risk. Audit processes in place had not identified these issues. However, the registered manager appropriately investigated and reported incidents and complaints. They analysed accidents and incidents for trends, the root cause, and to aid future learning. The service updated people following any safety incident involving them. The registered manager had an ‘Open Door’ policy, whereby anyone could approach them to discuss any issues.

People had access to healthcare and other professionals as and when required. A GP visited weekly. People were involved in decisions about changes to their care and support. One visiting professional told us about an instance whereby the service, “involved the person and their partner and gave full explanations of why the move was necessary.”

Staff knew where information from visiting professionals was recorded for them to view. Staff told us about care documents where any key information from professionals was updated as and when required.

Healthcare and other visiting professionals provided positive feedback about Belmont House Care Home. There was confidence in the registered manager. Professionals found arrangements to visit the provider worked well, and they had good relationships with staff. They told us care was recorded well. Professionals felt staff knew people and their needs well, and staff responded appropriately to those needs.

Processes were in place to ensure staff worked with people and professionals to establish and maintain safe systems of care. The provider listened to and considered the views of people, visiting professionals and staff. Key staff members accompanied visiting professionals to record any action taken and the support provided to people. The registered manager tried to continuously improve the process by which professionals visited the provider and recorded the support given to people.

Everyone we spoke to said they felt safe living at Belmont House Care Home. One person said, “I feel absolutely safe here. The care is wonderful. The staff are wonderful.” Another said, “Yes, it is safe. Definitely. The staff are brilliant and it’s a nice place.” Relatives were also confident their family members were safe. One told us, “I was worried at first when we decided to move [name] here, but I am happy now with what I see. The staff are great and friendly.”

Staff understood their role to keep people safe from neglect, abuse, and other potential harm. They knew how to escalate any safeguarding concerns. Staff believed people were safe living at Belmont House Care Home. One said, “I think residents are safe. We do regular checks on each resident. We have good communication throughout, so we know where the residents are at all times.”

We observed staff being attentive to people’s needs. Staff were friendly and displayed warmth when supporting people. We observed many positive interactions with people by care staff as well as by the wider staff team. It was clear most staff knew people and their individual needs well.

Robust procedures were in place to deal with safeguarding incidents, but care records were not always updated accordingly. Some people’s care records lacked relevant details about potential risk. The action staff should take due to known risk was not always clearly documented. However, appropriate systems and processes were in place to deal with any potential safeguarding incidents, and any concerns were reported quickly. Staff understood the importance of safeguarding and how to take appropriate action. Staff were committed to taking immediate action to keep people safe. The registered manager had a clear understanding of the Deprivation of Liberty Safeguards (DoLS), and this measure was only used when it was in the best interest of the person.

People’s risk management was not always robust and sometimes lacked clear instructions for staff. This put people at increased risk of avoidable harm. However, people were involved in decisions about changes made to their care and support, including how to manage risk. Some relatives told us they had been involved in the creation of care plans for their family members.

Some of the shortfalls we identified in relation to risk management highlighted that staff knowledge of how to effectively record and manage risk could be improved. Staff told us people were involved in decisions about the support they received. One said they, “engage in open communication, ask for [people’s] input, and provide options so they can make informed decisions about their care.”

We observed staff supporting people at a relaxed pace, being patient without rushing them. Staff were observed to reassure people when needed. Staff responded well when people communicated their needs.

The service did assess risks to people, but we found care records sometimes contained inaccurate information about people’s presentation and needs. Some people didn’t have a care plan in place for a specific health condition. Despite various layers of audit processes in place, some people’s care records had not been reviewed robustly enough to determine the missing and / or contradictory information we identified during the assessment. At our last inspection, we found the provider to be in breach of legal regulation relating to ensuring people always receive safe care and treatment. Although some improvements had been made, the issues we identified meant the provider had failed to make enough improvements to address this breach.

People told us they felt safe living at Belmont House Care Home. One relative said, “I think [person] is safe here. Staff come quick when needed. [Person] needs a hoist to get up and staff are always there when needed.” A visitor commented, “The design of the building is very good. There are wide corridors, to enable equipment to be moved. Not everyone thinks of things like that, but you can tell it has been designed for this purpose. The rooms are spacious, too.”

The registered manager explained how the service was trialling different equipment to ensure people were supported in the least restrictive way and to suit their needs. There had been robust considerations by the service in balancing visitor access with people’s safety. Staff told us they had the correct equipment to do their jobs safely, and all equipment was in working order. One said, “The equipment is safe and has the correct safety sticker on for test dates, etc. I have never come across anything that doesn’t work and if I did, I would report it straight away.” Another told us that, “Regular safety checks are conducted to ensure everything works correctly. If any equipment is found to be faulty, staff are trained to identify and report these issues promptly for repair, ensuring continued safety for residents.” Staff participated in fire drills. One told us, “I am confident that residents would be moved to safety quickly in case of an emergency. The home has well-practiced [sic] procedures and regular drills to ensure that all staff are prepared and can act efficiently to protect residents.”

We observed a tub of prescription thickening agent which was accessible to people and could have posed a risk of harm. When we alerted staff, they immediately secured this substance and made sure it was no longer accessible. We also observed prescription emollients stored in the en-suite bathrooms of some people. Bedrooms and bathrooms were accessible to any other people living in the same unit, and so could have posed a risk of harm. The management team was responsive to our feedback about these matters. However, the home environment was appropriately secure. Staff were required to enable access for anyone visiting.

Although risk assessments had been produced in respect of the risk of fire from emollients, the provider confirmed there were no risk assessments in place or information for staff in relation to the safe storage of this product within individual people’s bedrooms / bathrooms. Given that some people living with Dementia could potentially access this substance, the risk of ingestion of emollients had not been considered. The provider was responsive to our feedback and worked to ensure appropriate risk assessments were put in place. We found robust systems in place to ensure the maintenance of equipment and safety checks required. Relevant fire training, including fire drills, formed part of the mandatory training requirements for all staff.

We received mixed feedback from people about staffing numbers. A relative told us, “Staff are great. They know [person’s] needs. I think there are enough staff. They work hard.” One person said, “I do feel safe here, yes. I do wonder if they are understaffed at times, but I always get help when I need it. The most I had to wait was about 10 minutes, once, when I pressed the call bell.” Another told us, “The staff are good, but it could be better. I think they could do with more staff. I think they are trained well, but maybe need more [staff].” Another person said, "It is comfortable. I do feel that there should be more staff, however, especially at night.”

The registered manager told us the staff team had improved due to less agency staff being used. Staff told us there were the right skills in their teams to meet people’s needs. One said, "I think we have some really competent care staff." The provider’s 2024 staff survey summary showed most staff “felt supported by their colleagues and believed they had the right skillset to meet the needs of the residents.” It also noted, “Overall staff thought the training offering was good and sufficient to carry out their job well and that there was opportunity for them to progress.” One staff member told us, “Training is regularly updated, covering all aspects of resident care and safety, and ensuring that staff are skilled and knowledgeable in their roles.” Most staff told us there were enough of them to care for people at Belmont House Care Home and keep people safe. However, some staff told us the service would benefit from having more staff, especially on a night.

We observed staff responding to people’s needs in a timely manner. There appeared to be enough staff on duty. Staff were always visible in all areas during our visits. We observed staff engaging positively with people, showing respect and being attentive to people’s individual needs. However, we observed some language used by staff to address people was not always appropriate. The registered manager was responsive to feedback about this and confirmed specific training for staff relating to supporting people living with Dementia was underway. The training will include a module on ‘Communication and Relationships’.

Processes were in place to monitor any changes to people’s needs and for staffing requirements to be determined accordingly. The service had appropriate recruitment checks in place. Staff files contained relevant training information, and there was a comprehensive induction for new staff members. The registered manager had good oversight of staff training and ensured staff completed mandatory modules. The registered manager also told us about additional training being sourced to further develop staff and improve their knowledge and skills.

People were clean and well-presented. People told us their bedrooms were kept clean. One person said, “As you can see, my room is lovely. It is safe and always kept so clean by staff. Another told us, “My room is nice and comfy. Staff always keep it clean.” A visiting professional noted that, “The home always seems clean.”

Staff knew how and when to wear Personal Protective Equipment (PPE). Staff told us cleaning is a continual process. One said, “Yes, Belmont is cleaned properly. I’m impressed with how residents’ rooms are always tidy at the start of my shift, along with the rest of the facility. The cleanliness is commendable.”

Staff were observed wearing PPE at appropriate times. The home environment was clean and well-maintained, within a purpose-built structure in good condition and well-decorated.

The service had comprehensive decontamination and cleaning records in place for each area of the home environment. The ‘Resident of the Day’ initiative ensured deep cleaning of people’s bedrooms was completed regularly. Communal bathrooms contained up-to-date cleaning schedules.

People didn’t always receive their medicines at the right times or as prescribed. Some care plans for people with complex needs were not detailed enough and sometimes lacked clear instructions for staff. This put people at increased risk of avoidable harm. However, people told us they knew why they took their medicines. One person said, “Staff look after all my medication. I know what I take and why.” We observed people being given oral medicines in a kind and patient manner.

Staff who administered medicines told us they had received proper training to do so. Staff medicines competencies were assessed on a regular basis, and we observed evidence of this. Staff knew before administering medicines, they must consider information in a person’s care plan as well as information contained on the electronic Medication Administration System (eMAR). Despite staff being aware of what information to check before administering a person’s medicine, they had not identified the discrepancies in recorded information we found, which indicated further training and knowledge may be required.

Staff did not always follow instructions for prescribed medicines. Guidance to support staff on the application of topical medicines (such as creams) was not always robust enough to provide assurances that people were receiving their topical medicines as prescribed. Insufficient guidance was in place to safely guide staff in the administration of medicines prescribed on a ‘when required’ basis and when variable doses of medicines were prescribed. Guidance and processes to ensure the safe management of people’s Percutaneous Endoscopic Gastrostomy (PEG) feeds were not always in place. Processes to support the recording of thickening agents (medicines used to thicken food and fluids for people with swallowing difficulties) were not robust, and we found inconsistencies across both recording systems. The medicines audits we reviewed had only identified some of the issues we found during the assessment, but those which had already been highlighted had not yet been actioned. However, controlled drugs were stored securely, and up-to-date medicines policies were in place. The provider was responsive to our feedback and started to implement changes following the assessment.