23 August 2022
During an inspection looking at part of the service
Belmont House Care Home is a residential care home providing personal and nursing care to up to 106 people. The service provides support to both older people and younger adults, some of whom are living with dementia. At the time of our inspection there were people 69 people using the service.
Belmont House Care home is a large purpose-built home split across five separate units. One of these units had recently been refurbished but was not in use at the time of the inspection. Two of the units specialise in supporting people living with dementia.
People’s experience of using this service and what we found
Care records did not always provide enough guidance for staff around how to deal with people’s known needs or behaviours. Records to monitor and document care provided, and the related risks, were not always completed.
Feedback about staffing levels in the service was varied and improvements had been made to staffing with a reduction in the use of agency staff over recent months. However, people still felt they needed more staff to assist them and run activities in the service. The registered manager was actively trying to recruit more staff. There is a continued recommendation about the review of staffing levels and deployment within the service.
Audits and checks were in place to ensure the safety and quality of the service. However, these were not effectively embedded and had therefore not highlighted issues we found on inspection.
Staff had a good understanding of safeguarding and action was taken to mitigate risk.
The environment was clean, well maintained and safe for the people living there. Regular checks were completed to ensure the premises were safe and staff carried out regular fire drills and evacuations.
Feedback about the registered manager and leaders in the service was positive and people felt supported. Staff had a positive approach towards their work and the people they supported, they had a strong desire to improve the quality of the service they provided.
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.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 15 December 2020). 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 some improvement had been made but the provider was still in breach of regulations.
Why we inspected
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Belmont Care Home on our website at www.cqc.org.uk.
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 records and governance at this inspection and have made recommendations around staffing levels and deployment.
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.