Belmont House Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Our rating for this key question remains requires improvement. Despite a previous breach of legal regulation in relation to governance, with action taken by the provider to make some improvements, the governance procedures in place had failed to highlight the issues we identified during this assessment. There was a lack of consistent and accurate recording of information in some people’s care records. Learning from incidents was not always embedded. Continued work was needed to ensure sustained improvement in accurate record-keeping. However, the provider collaborated well with healthcare and other professionals to ensure people received appropriate care and support. Appropriate policies were in place to protect staff from discrimination. Most staff spoke positively about the management team. We observed staff behaving in a manner which adhered to the provider’s values. Leaders were open and transparent during the assessment process, and they understood ongoing improvements were needed. The provider was responsive to our feedback and sought to implement changes during and following the assessment.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff demonstrated the provider’s values, and staff felt the registered manager led by example. Staff feedback said the culture at Belmont House Care Home encourages them to treat people well. One staff member said, “The company upholds equality and inclusivity, promoting a positive working environment for everyone.” Another said, “I believe the management are fair because they consistently communicate openly, address concerns promptly, and make decisions that support both staff and residents. Their actions and decisions reflect a commitment to integrity and competence.”

The registered manager had an ‘Open Door’ policy in place, encouraging staff and people to approach them and discuss any concerns. Team meetings allowed for open discussion and team reflection on key issues, enabling staff to contribute towards shaping decisions. Staff were able to proactively offer ideas for improvements.

We received positive staff feedback about the registered manager of Belmont House Care Home, with staff expressing confidence in them. One said, "I think [registered manager] has great leadership qualities." Another told us they “can always speak up about any work-related concerns because management fosters an open and supportive environment where feedback is welcomed and addressed constructively.” One staff member said, “I believe the managers have the right training to do their job well. They visibly demonstrate solid understanding of best practices and handle their responsibilities with competence and professionalism.”

We identified some people’s care records did not contain enough information with regards to known risks and diagnosed health conditions. Despite processes in place to check care records, leaders had not identified missing and contradictory information we found. Leaders were responsive to assessment feedback and resolved issues immediately where they were able to do so. The registered manager demonstrated a positive, compassionate, listening culture that promoted trust.

Most staff told us they were comfortable speaking up and challenging the way things were done if required. One said, “I have had to speak up a couple of times, and the managers have listened and responded effectively straight away.” Most staff believed the culture at Belmont House Care Home encouraged speaking up. One told us that “staff are encouraged to voice their worries without fear or hesitation.” Another said, “[Registered manager] has proven to me that [they] can be trusted.” However, not all staff believed the management team to be approachable, and not all staff felt comfortable in approaching the management team to discuss any concerns. This indicated further work was needed to ensure that all staff feel comfortable speaking up to raise concerns appropriately as and when they may arise.

There were multiple options available to staff in terms of raising any concerns. The registered manager had an ‘Open Door’ policy in place whereby staff were encouraged to go and speak to them about any concerns or suggestions. The provider’s Whistleblowing Policy gave staff assurances as to their protection if they raised a concern, as well as information about avenues of support for staff.

Most staff told us they were treated fairly and equally. One said, “[Registered manager] promotes inclusivity and diversity, contributing to a positive and competent environment for all.” Another said, “I think I am treated fairly and if [there’s a] problem, it’s sorted out quickly.” Another told us, “If there is one thing I am very happy about while working at Belmont, it is the fair and equal treatment of staff. The company upholds equality and diversity, promoting a positive working environment for everyone.” However, some staff said they just felt like a ‘number’ to the provider. One staff member told us they didn’t feel able to request days off and believed the rota being confirmed “last minute” prevented them from being able to plan things outside of work.

The provider is an equal opportunities employer. This means a commitment to not treat its staff (or people applying for jobs) unfairly because of race, national or ethnic origin, age, being pregnant or on maternity leave, marriage and civil partnership, disability, sex, gender, sexual orientation, gender reassignment, religion or belief. Comprehensive policies were in place covering Recruitment and Selection, and Equality, Diversity and Inclusion.

The registered manager evidenced they had good oversight of accidents and incidents. An additional deputy manager post had been introduced which ensured more support for the registered manager. The provider felt improvements had been made to health monitoring. The registered manager explained that charts and checks were completed by senior staff members, meaning good clinical oversight. We saw evidence of improved oversight of bowel monitoring charts and associated follow-up action taken when necessary. The registered manager believed care plans were much improved, but it was recognised that work was still needed to further enhance people’s documentation. However, despite the audit processes in place and the extra layers of support and oversight from senior staff members and deputy managers, the issues we found during the assessment had not been identified and addressed in audits by staff.

Processes were not sufficiently robust to detect the missing and / or contradictory information we identified in care records. Despite action plans in place with new audit processes introduced, the provider had failed to identify the issues we found during our assessment.

People had access to a visiting GP who collaborated well with the provider. Healthcare and other visiting professionals shared information and worked in partnership with the provider to ensure joined-up care for people.

The registered manager encouraged effective partnership working with healthcare and other professionals to ensure people’s needs were met. The registered manager had made repeated attempts to improve collaboration and ensure effective documentation of the care provided by visiting healthcare professionals.

Visiting professionals gave us positive feedback about the working relationship they had with Belmont House Care Home and its staff. Professionals told us staff were helpful. Staff were noted as being responsive during and after any visits by professionals. One professional said, “The manager and deputy manager are always approachable.” Another told us the provider had “been very receptive” with “information readily available.”

Wherever possible, the provider had a senior care staff member accompany any visiting professional to ensure relevant information was captured and documented accordingly. The registered manager used local networks to share learning and discuss best practice. These networks were used to discuss potential solutions to issues encountered. The registered manager sought innovative ideas to gain better outcomes for people.

A provider staff satisfaction survey in 2023 found most staff believed the culture encouraged the sharing of ideas to move forward and think differently. One staff member said, “I’m always asked for my opinion.” They also told us “[Registered manager] will always take on board ideas.” Another said, “If I have an idea to improve something, I share it with any member of the management or supervisory team. They are approachable and take my ideas seriously, ensuring that concerns are addressed promptly and effectively.” However, although staff felt able to make suggestions for improvement, the inconsistencies we found in care records indicated that some improved knowledge of best practice was required to effectively embed lessons learned.

The service had made some improvements in health monitoring and recording within care records, but this was not consistent. For some people, key information in their care records was either missing or did not contain sufficient detail to inform staff how best to care for that person. Some people’s risk assessments did not contain enough detail, with some information being contradictory to that held about the person elsewhere in care records. Although the service investigated incidents thoroughly, sometimes key information was not recorded accurately in people’s care records following this. Despite previous breaches of legal regulation in relation to good governance and ensuring people’s safe care and treatment, the provider failed to make enough improvement to fully address this. We found that continued improvement of the recording of robust and accurate information within care records was required. The provider was responsive to our feedback, and positive changes were made during and following the assessment.