The Belfry Residential Home

At our last inspection we found the provider to be in breach of legal requirements relating to risk management, staffing and safe medicines management. At this assessment, the provider has made enough improvement in relation to identifying and assessing risks to people, ensuring enough suitably qualified, competent and experienced staff and safe medicines management and was no longer in breach of these legal requirements.

We reviewed 6 quality statements under this key question; Learning culture, Safeguarding, involving people to manage risk, Safe and effective staffing, Infection prevention and control and Medicines optimisation.

At this assessment we found a positive culture of safety based on openness and transparency. Although concerns about safety were listened to and investigated, they were not always reported where required. The service used a lesson learned approach to share information to improve the quality of the service to people and staff. Staff had been recruited safely and there were enough suitably trained staff to meet people’s needs. People received their medicines by staff who were trained to do so, however we did find the provider had not undertaken their own medicine competency assessments for agency staff who regularly worked the night duty shift, relying on the agency’s training. Following the assessment the provider immediately completed competency assessments with the agency staff identified for their own assurances. When carrying out checks of the medicines room storage areas we found some out of date dressings which had not been disposed of and medicine pots used to administer people’s medicines stored inappropriately. The registered manager rectified this during our visit. Care plans contained risk information relating to individual people’s needs. Infection prevention and control measures were in place and the provider had a service improvement plan underway to update some areas of the home.

We reviewed 4 quality statements under this key question; Assessing needs, delivering evidence-based care and treatment, how staff, teams and services work together and Consent to care and treatment. We found that people were involved in their care and their consent to receive care was sought by staff and the management team. Where people could not consent to care, the appropriate legislative processes had been followed. People had their needs assessed thoroughly before care commenced and were involved in how their care would be delivered. People told us care was consistent and they were asked for their consent before care began or changes were made to their care.

We reviewed 1 quality statement under this key question: Independence, choice and control. Staff respected people’s privacy and dignity and encouraged people to remain independent. People were supported by a caring staff group who respected their choices and preferences.

We reviewed 4 quality statements under this key question: Person-centred care, listening to and involving people, Equity in experience and outcomes and Planning for the future. People and those important to them were supported to make decisions about their own care and support and staff treated people as individuals providing a person-centred approach. People and their relatives were supported with the transition to move into the home. There was regular communication with healthcare professionals to ensure people’s health needs were met. Relatives were involved in supporting people with their health needs, through regular communication with staff at the home and other external health care services. Discussions with people and relatives regarding end of life remained ongoing in order to update care plans.

At our last inspection, we found the provider to be in breach of a legal requirement relating to their governance and oversight of the service. At this assessment, the provider has made enough improvements and is no longer of breach of this legal requirement.

We reviewed 4 quality statements under this key question: Shared direction and culture, Capable, compassionate and inclusive leaders, Governance, management and sustainability and Partnership and communities.

Staff were clear about their responsibilities and roles and felt supported by the management team and registered manager. Although the providers governance systems - which were used to monitor the quality and safety of people’s care - had improved and they were no longer in breach of a legal requirement, further improvements were required. Robust assurances around governance, reporting of events in the service, effective monitoring of medicines management and oversight of agency records all required improvements. The registered manager took immediate action to update agency staff records and amended their medicines auditing processes. Although we did not find these improvement needs directly impacted the safety and quality of people’s care, and any future risks were mitigated by the actions taken, time is required to demonstrate the improvements made are sustained.