16 June 2022
During a routine inspection
Bellsgrove Care Home is a residential care home providing personal care and accommodation for up to 15 older people including those who live with dementia. The service is set over three floors and has a communal lounge area and dining area on the ground floor. A lift connects all levels. At the time of the inspection 15 people were living at the home.
People’s experience of using this service and what we found
Risks associated with people's care were not always assessed in a safe way, particularly in relation to the use of bed rails and supporting people to eat. People and their relatives told us they felt safe and we checked that the provider had systems in place to ensure safe recruitment of staff. Staff followed good infection prevention and control practices. There were sufficient staff, however, we have made a recommendation that staff are efficiently deployed in order to engage with a people who remain in their rooms.
We found that the environment did not meet the needs of people who lived with dementia. Some people told us activities were not varied enough and the activities we observed did not always serve to engage those with more profound dementia, especially those who remained in their rooms for periods of time.
The provider did not always ensure that people accessed healthcare professionals in a timely manner. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.
Quality assurance processes were not effective in identifying and delivering required improvements to the service which meant people were at risk of not receiving a consistent or safe service in line with their needs. There was a lack of robust management oversight of the service.
Staff told us there was good teamwork amongst the care staff but some said they did not always feel valued by the provider. Family members told us the registered manager was approachable and available to them and that there was a friendly and homely atmosphere at Bellsgrove.
People and their family members told us that staff were consistently respectful, kind and caring and we observed how staff engaged with people in a warm and friendly way. People’s needs were assessed prior to moving into Bellsgrove Care Home. Care plans were detailed and staff knew how to support people according to their wishes.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
We carried out a focused inspection on 14 February 2021 when this service was rated requires improvement (published 21 January 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider had not made enough improvement and remained in breach of regulations. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
This inspection was carried out to check if the provider had followed their action plan and to confirm they now met legal requirements.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to assessment of risk, medicines management, timely access to healthcare professionals, environmental design, lack of meaningful activities and governance of the service.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.