This inspection took place on 6, 9 and 12 March 2018. The first day of our inspection was unannounced; we gave notice of our visits on the second and third day.

Belmont House Care Home is registered to provide residential and nursing care for up to 106 older people and people who may be living with dementia. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service is purpose built and accommodation is provided in five separate ‘suites’, spread over three floors. On the ground floor, the Courtyard Suite provides residential care for up to 30 people and the Garden Suite provides nursing care for up to 14 people. On the first floor, the Park Suite provides residential care for up to 17 people and the Promenade Suite provides nursing care for up to 26 people; both of these units specialise in supporting people who may also be living with dementia. On the second floor, the Springwater Suite provides nursing care for up to 14 people.

At the time of our inspection, 94 mainly older people and people living with dementia and nursing needs were using the service.

The service had a registered manager. They had been the registered manager since August 2013. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection in January 2017, we rated the service ‘requires improvement’ and identified two breaches of regulation. We asked the provider to take action to ensure medicines were managed safely and to improve the quality monitoring and governance of the service. At this inspection, medicines were still not managed safely. Audits had not been effectively used to identify and address the concerns we found.

This was the third inspection where the service was found to be in breach of one or more regulations and rated requires improvement. This showed us the provider had not operated effective systems and processes to ensure the quality and safety of the service.

We found two continued breaches in regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the registered provider to take at the end of this report.

People who used the service told us they felt safe. Staff had training to enable them to identify and respond to safeguarding concerns. Allegations of abuse were investigated in consultation with the local authority safeguarding team. The provider had systems in place to respond to complaints about the service and took action to make improvements when necessary.

Robust recruitment checks helped ensure suitable staff were employed. We received mixed feedback about staffing levels. We found staffing levels were sufficient to meet people’s needs, but spoke with the registered manager about continuing to monitor staff deployment across the service.

The provider had taken positive steps to create and maintain a dementia friendly environment. The service was clean, tidy and generally well-maintained. Systems were in place to reduce the risk of spreading infections.

Staff received a comprehensive induction and regular training to develop the skills needed to provide safe and effective care. The provider was proactive in offering additional training opportunities to support continued professional development. Nurses were supported to develop and maintain their clinical skills.

People gave generally positive feedback about the food and staff provided effective support to ensure people ate and drank enough. Concerns regarding weight-loss were shared with

The inspection took place on 24 and 25 January 2017. The first day was unannounced.

We previously carried out an inspection in October 2015, where we found the registered provider was not meeting all the regulations we inspected. We found the registered provider did not have suitable arrangements in place for obtaining, and acting in accordance with the consent of people in relation to their care and treatment as required by the Mental Capacity Act 2005. We also found that the registered provider did not have suitable arrangements in place to ensure the deployment of staff protected people from the risk of harm. We told the registered provider they needed to take action. We received an action plan from the registered provider telling us what they were going to do to address the shortfalls.

During this inspection we found that the assurances from the registered provider had been implemented with the necessary improvements being made across the service. However, we found shortfalls relating to the safe management of medicines. We also identified failings in the quality monitoring systems.

Belmont House provides residential, nursing and personal care for up to 106 people. The home is divided into five separate suites, spread over three floors. The Courtyard suite provides residential care for up to 30 people. The Garden and Springwater suites both provide nursing care for 14 people each. The Park suite provides residential care for up to 17 people who are living with dementia. The Promenade suite also provides care for 26 people who may be living with dementia, but also need nursing care.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Overall people told us they felt safe. Staff understood how to safeguard people from abuse. We saw from the rotas that staffing levels were based on the registered provider’s assessment of people’s needs. However we recommended that the registered provider review their staffing levels more frequently to make sure there were no gaps in staffing provision. The recruitment process was robust and staff completed an induction when they started work. This reduced the risk of unsuitable people being employed. People were supported and cared for by skilled, well trained staff who took pride in their work.

We found that people were encouraged to exercise choice and control in all aspects of their lives wherever possible. Key people were involved in most of the best interests meetings for people who required additional support with decision making.

Any risks around peoples care were identified. Where risks were identified action was taken to minimise these whilst protecting individual's rights and freedoms.

People had food and drink to meet their needs. People were supported to receive their medicines as prescribed and to access their health care appointments to make sure they received appropriate care and treatment.

We observed good relationships were present between people who used the service and staff. Staff were knowledgeable about the people they supported. This was confirmed in feedback we received about the service. During the whole inspection we noted multiple examples of good practice, excellent care delivery and an atmosphere of caring, compassion and a relaxed environment.

People had comprehensive care and support plans in place. However, the level of detail varied across the service. The information guided staff on people’s preferred approach to meet their care needs. An example of this was how one person liked to have their clothes protected whilst eating at the table.

A complaints procedure was in place. People confirmed they knew who to speak to if they

Two inspectors carried out this inspection. During the inspection, the inspectors focussed on answering five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we looked at records for eight people who used the service. We spoke with the manager and deputy manager. We spoke with nine people who lived in the home and four relatives of people who lived in the home. We also spoke with eight care and nursing staff. We reviewed records relating to the management of the home.

Below is a summary of what we found. The summary describes what people who used the service and staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We had received information prior to carrying out the inspection; this included information regarding the staffing levels and the impact that this was having on the delivery of safe support to people. The manager and deputy manager confirmed during our visit that there had been some changes to staffing structures recently. This had resulted in some vacancies and had caused there to be minor staff shortages on some occasions. When we spoke with people who used the service and relatives, comments included “I get a general sense that staff are very busy but they do seem to have time to spend with people” and “I don’t have to wait when I ring the bell”.

We found that the service undertook checks on staff before they commenced employment in the home. This included checks of people’s criminal records and identification as well as employment history and references from previous employers. Staff also underwent an induction training programme which included shadowing experienced members of staff and completion of mandatory training. This ensured that staff were safe to work with vulnerable people.

There were records showing that staff accessed regular training, both mandatory and specialist. This included training around areas such as dementia, person centred support, infection control and safeguarding. This meant that staff had the appropriate training and experience to deliver support to people using the service.

Is the service effective?

The service was split into five separate units which included a dementia unit, a dementia nursing unit, a nursing unit and a residential unit. This meant that people could be supported according to their individual needs.

People had an individual care plan. We saw that care plans contained useful information and in some cases families had been involved in the development of these. In one case the person had written their own care plan and had recorded how they wished to be supported. This involvement from people themselves or their families meant that the care and treatment being received was effective for those using the service. The risk assessments we saw in the records were sufficiently detailed to identify and minimise risks. The service was appropriately assessing risk and providing guidance for staff about to how to manage and minimise these risks.

When we spoke with people who used the service they were very pleased with the support they received from staff. One person told us “No complaints, I am very happy with the care”. When we spoke with staff they told us that they felt they were providing good and effective care. None of the staff we spoke with felt that people were not getting the care they needed with regard to eating and drinking, personal care and medication.

Is the service caring?

All the staff we spoke with were enthusiastic to provide a sustainable, effective service. Individual staff spoke confidently about the high standard of care they were expected to provide. The manager and deputy management were also keen to ensure that the service was offering the best quality service it could.

When we spoke with people who used the service they were very complimentary about the quality of support that was provided by staff. One person told us “Staff are very kind and helpful”. The interactions we observed throughout our visit were very good. Staff spoke with people in a friendly and clear manner. When people were assisted to move or complete an activity instructions and support was straightforward and appropriate in nature. Staff knew people well and offered care that was calm, clear and friendly.

Is the service responsive?

There were audit systems in place regarding the environment, delivery of care, documentation and people’s satisfaction with the service they received. This allowed management to monitor the quality of service. The systems in place for highlighting issues and learning from accidents, incidents, surveys and resident meetings, staff feedback and complaints were used to lead to improvements in the service.

The management arrangements had recently been restructured and this had resulted in some changes in the staff team. This meant that there was on-going work being completed with regard to duties and responsibilities within the new structure.

We spoke with people who used the service about the ways they were able to feedback and how this information was used. One person told us “I feel confident the manager would address any issues”. A relative told us “We have only had minor niggles which get resolved very easily and quickly”.

Is the service well-led?

Due to changes in the structure at the service there had been some upheaval in staffing arrangements. There were some vacancies that were being recruited to at the time of our inspection and the impact of this was being managed by both the manager and other senior staff.

The manager and the deputy manager and team leaders had spent time defining their roles and this process was now being undertaken for the less senior roles. All the staff that we spoke with felt that the manager and senior management team were focussed on the service being high quality. One staff member told us “We are a good team all work well together”. Another told us “I feel the team work well together, I feel able to raise issues with the manager and in staff meetings and I get good support from unit manager”.

This inspection took place on 27 and 28 October 2015 and was unannounced.

At our last inspection on 2 June 2014 the provider was meeting the regulations that were assessed.

Belmont House offers residential, nursing and personal care for up to 106 people. The home is divided into five separate suites, spread over three floors. The Courtyard suite provides residential care for up to 30 people. The Garden and Springwater suites both provide nursing care for 14 people each. The Park suite provides residential care for up to 17 people living with dementia, while the Promenade suite provides nursing care for up to 26 people living with dementia. The service is registered for 106 people to take account of occasions where a couple may wish to share a room.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service had experienced difficulties in recruiting staff, particularly qualified nursing staff and there was a high use of agency staff. The registered manager told us they requested the same members of staff from the agency in order to provide some consistency in care for people. The provider had placed the recruitment of staff as a high priority.

On both days of the inspection there were adequate numbers of qualified and skilled staff working at the service. However, during our second day of inspection on one particular unit staff were not deployed effectively which placed people at risk of potential harm. There was a new unit manager and they and the registered manager acknowledged some action was required to ensure staff worked together in order to ensure people had their needs met and were not a risk of harm. This is a breach of Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staffing. You can see what we have asked the provider to do at the end of the report.

Some staff had received training with regard to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. However, where people lacked capacity, the restrictions that staff and the provider had put in place may amount to depriving some people of their liberty. An application under the Mental Capacity Act Deprivation of Liberty Safeguards had not been made. This is a breach of Regulation 11 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staffing. You can see what we have asked the provider to do at the end of the report.

People and their relatives told us they felt safe at Belmont House. Staff knew the correct procedures to follow if they considered someone was at risk of harm or abuse. They received appropriate safeguarding training and there were policies and procedures to support them in their role.

The service had systems in place for recording and analysing incidents and accidents so that action could be taken to reduce risk to people’s safety. Risk assessments were completed so that risks to people could be minimised whilst still supporting people to remain independent.

Staff received on going training and management support. They received a range of training specific to the needs of people they supported.

People received their medicines at the times they needed them. The systems in place meant medicines were administered and recorded properly and this was audited regularly by the service and the dispensing pharmacist. Staff were assessed for competency prior to administering medication and this was re-assessed regularly.

People had their nutritional needs met. People were offered a varied diet and were provided with sufficient drinks and snacks. People who required special diets were catered for.

People had good access to health care services and the service was committed to working in partnership with healthcare professionals.

People told us that they were well cared for and happy with the support they received. Staff were patient, attentive and caring; they took time to listen and to respond in a way that the person they engaged with understood. They respected people’s privacy and upheld their dignity when providing care and support.

People knew how to make a complaint if they were unhappy and all the people we spoke with told us that they felt that they could talk to any of the staff if they had a concern or were worried about anything.

Staff spoke positively about the registered manager. They told us she was supportive and encouraged an open and inclusive atmosphere. People living at the service, their relatives and staff were provided with opportunities to make their wishes known and to have their voice heard.

The provider completed a range of audits in order to monitor and improve service delivery. Where improvements were needed or lessons learnt, action was taken.