About the service: Belvedere Care Home is a residential care home that was registered to provide personal care for up to 38 people. On the day of our inspection, the service was supporting 25 people. Some people using the service, were living with dementia.

People’s experience of using this service:

The registered manager had made some improvements since our last inspection of 6 November 2018. However, there remained breaches of the regulations.

People were not always safe. Risks to people’s health and wellbeing had not always been identified or managed appropriately. Risk assessments and care plans had not always been updated when people’s risks or needs had changed. Accident and incident records and body maps were not always completed after an injury or incident. We found hazardous cleaning products and a small canister of butane gas were accessible in people’s bedrooms. Medicines were not always managed safely; we observed an instance of unsafe practice.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service were not always followed. Some assessments of people’s capacity to make decisions were generic and not decision-specific, and no consideration had been made to a person’s capacity when under the influence of alcohol. One application made under the Deprivation of Liberty Safeguards contained contradictory information. Staff were not always aware of who had capacity and who did not.

Care records we looked at did not evidence people had been involved in the development or reviewing of their needs. These records lacked information about people’s histories, past times and life experiences. Care plans were not person-centred and reviews did not always reflect changes in people’s support needs. Those people considered to be at the end of their life did not have end of life care plans in place.

We received mixed responses in relation to the activities available within the home, with some people saying there was nothing for them to do. Whilst some improvements had been made we found one person deemed as requiring stimulation during the day was not in receipt of this; we did not observe any staff member interacting with them.

We found concerns around records and them not being kept up to date, some were hand written and difficult to read. Audits were not sufficiently robust to identify the concerns we found on inspection. Action plans submitted to us did not reflect what we found on inspection.

People who used the service told us they felt safe from abuse. They told us there were enough staff on duty to meet their needs and we observed a calm atmosphere throughout the inspection. There had been improvements in the recruitment processes, environment, staff meetings, supervisions and appraisals and meetings for people who used the service. There had been an increase in staff training, although concerns we found during our inspection indicated that further training was required.

The provider had recently instructed a consultancy firm to support the registered manager to make improvements within the service. The registered manager was new in post and was open and transparent throughout the inspection. Whilst some improvements had been made these need time to become embedded and sustained so they become part of normal practice. There was a continuing failure to meet the regulations.

Rating at last inspection: At the last inspection this service was rated inadequate and placed in special measures (published 4 February 2019).

Why we inspected: We carried out this inspection based on the previous rating of the service.

Enforcement: Full information about CQC's regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up:

The overall rating for this service remains ina

What life is like for people using this service:

The service had deteriorated since our last inspection. Risks were not identified, managed or monitored to ensure people were safe. Information received from speech and language therapists was not consistently transferred to care records to direct staff on managing risks. Medicines were not always managed safely, in particular the use of thickeners. People were not always protected by good infection prevention and control procedures. Equipment within the service such as hoists and utilities such as gas was checked regularly. Despite some staff not being up to date with safeguarding training, they understood their responsibilities for keeping people safe. People using the service and their family members told us they felt safe. Improvements had been made in the recruitment of staff; safe processes were followed. People and staff members told us there were adequate staff on duty.

The service had deteriorated in relation to the skills, knowledge and experience of staff members. There were significant gaps in training, in particular to meet the needs of people with health issues. Staff did not receive supervisions and appraisals in line with policies and procedures. The provider was not working within the principles of the Mental Capacity Act (MCA) and had failed to apply for the correct authorisations to deprive people of their liberty lawfully. Care plans did not consistently identify desired outcomes for people. People were not consistently supported to eat and drink enough throughout the day. There had been some improvements made to the suitability of the environment since our last inspection.

People were not always supported to express their views or be involved in making decisions about their care. Care plans and their reviews had not been signed by people. We saw staff were respectful of people’s privacy and dignity. Visitors were made to feel welcome at the service. People told us staff were kind and caring and positive interactions were observed during our inspection.

There had been a deterioration in how people’s needs were responded to. Care plans did not consistently reflect people’s current needs and were not person centred. People’s end of life wishes had not been considered. There was a lack of meaningful activities to keep people stimulated and prevent boredom. All the people we spoke with knew who to speak with if they wished to raise a complaint.

There had been a deterioration in the leadership of the service. The registered manager lacked knowledge around the regulations, legislation and best practice guidance. There was a lack of robust systems in place to check on the quality and safety of the service which had resulted in a lack of improvements from previous inspections. The service was not well-led.

More information in detailed findings below

Rating at last inspection: Requires improvement (report published 7 August 2018).

About the service: Belvedere Care Home is a residential care home that was providing personal and nursing care to 27 people at the time of the inspection.

Why we inspected: This was a planned inspection based on the rating at the last inspection. We saw the service had deteriorated since our last inspection and the rating had changed to inadequate.

Enforcement: Full information about the Care Quality Commission’s (CQC) regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals are concluded.

Follow up: The overall rating for this service is inadequate and the service is therefore in special measures. Services in special measure will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough i

We undertook an unannounced focused inspection of Belvedere Care Home on 25 May 2018. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection of 27 March 2018. The team inspected the service against four of the five questions we ask about services: is the service well led, safe, effective and responsive. This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Key Question through our ongoing monitoring or during our inspection activity so we did not inspect it. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Belvedere Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Belvedere Care Home accommodates up to 38 people. On the day of our inspection there were 28 people using the service with varying levels of needs; some people were living with dementia.

The service had a registered manager in place, who was also the provider. 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.

We met with the provider on the 15 May 2018, to discuss the significant concerns that had been raised following our inspection on 25 May 2018. During this meeting, the provider assured us and provided evidence to demonstrate that immediate action was taken to address some of the issues after our inspection. They discussed with us the improvements they felt had been made.

During this focused inspection, we found some improvements had been made and action taken to address significant concerns from our last inspection. However, there remained a continuing breach of regulations as quality assurance systems, such as audits, and monitoring of the service were not effective.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals are concluded.

We saw some audit forms had been put in place, although not all of them had been commenced. In order for improvements robust auditing systems need to be in place and embedded into daily routines.

Risk assessments had been put in place since our last inspection. Risks associated with the environment had been assessed and control measures identified. Those people with health associated risks such as falls or choking had also been assessed and risk management plans put in place. These improvements would need time to become embedded into daily routines and time to assess if these improvements could be sustained.

Equipment within the service, such as gas boilers which were unsafe, had been replaced with new. Moving and handling equipment within the home had been service and deemed as safe to use. Regular checks of equipment need to be maintained to ensure it remains safe to use.

Whilst only two people had been employed since our last inspection, we saw the recruitment process for these people was safe. Robust recruitment processes and systems need to be maintained to ensure any prospective employee is deemed safe to work with vulnerable people.

During our tour of the building, we noted new carpets had been fitted in both some communal areas and some bedrooms. The decoration of one bedroom had also been undertaken since there had been a water leak.

The registered manager showed us the new training matrix they had in place. We saw 12 staff had undertaken moving and

This comprehensive inspection took place on 27, 28 and 29 March and 13 April 2018. The first and last day of our inspection was unannounced. We last inspected the service on 17 and 18 July 2017 to undertake a focussed inspection due to a number of concerns we had received.

Belvedere Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Belvedere Care Home accommodates up to 38 people. On the day of our inspection there were 29 people using the service with varying levels of needs; some people were living with dementia.

The service had a registered manager in place, who was also the provider. 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.

At our focussed inspection of 17 and 18 July 2017 we found breaches in the regulations; this related to safe management of medicines, failure to adequately assess risks to people and lack of person centred care plans. We therefore asked the provider to make improvements. We received an action plan from the provider indicating how and when they would meet the relevant legal requirements.

During this inspection we found some improvements had been made around the management of medicines but was still in breach and found the service to be in breach of regulations in relation to care planning and risk assessing. We found the service to be in breach of six regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in respect of Regulations 12, safe care and treatment, Regulation 9, person centred care, Regulation 17, good governance, Regulation 18, staffing and Regulation 19, fit and proper persons. This included shortfalls in the effective management of risks of harm and abuse within the service, failure to ensure equipment in use by the service was safe, failure to ensure the recruitment of staff was safe, inadequate staffing levels, shortfalls in staff training, supervision and appraisals, restrictions placed on when people could access food and drink and failure to demonstrate oversight and compliance with the regulations by the registered manager.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals are concluded.

We have also made a recommendation relating to control of substances hazardous to health (COSHH).

The risk assessments that were in place did not accurately reflect current risks and had not been reviewed. Those risk assessments did not direct staff on how to manage these or how best to support people. Advice from external healthcare professionals had not been included in care plans or passed on to staff and had not been followed. Three out of four staff members told us they had never seen any risk assessments in relation to people who use the service. Risks or hazards within the environment had also not been considered.

Moving and handling equipment within the service, such as hoists, had not been serviced. We saw one hoist was in a poor state of repair and was being used. We drew this to the attention of the registered manager and this was withdrawn from use until such time as it had been serviced and inspected by an approved service agent.

There were no records of maintenance and service for any gas appliances. This included the home’s four gas boilers. These concerns were brought to the attention of the registered manager who arranged for ‘Gas Safe’ engineers to attend the home during the inspection. These were in a state of dis

This inspection took place on the 17 and 18 July 2017. We carried out an unannounced comprehensive inspection of this service on 7 June 2016. After that inspection we received concerns in relation to attitudes of staff members including the registered manager, infection control, staffing levels, lack of leadership and inadequate care plans and risk assessments. As a result we undertook a focused inspection to look into those concerns.

This report only covers our findings in relation to the concerns raised. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Belvedere Care Home on our website at www.cqc.org.uk

Belvedere Care Home is a purpose built detached home close to the centre of Accrington, Lancashire. Accommodation is provided over three floors. The home is registered to provide accommodation and personal care for up to 38 people. On the day of our inspection 24 people were living at the home.

The service had a registered manager in place at the time of our inspection. 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.

During this inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We saw risks had been identified but no further action had been taken to minimise the risks to people who used the service. For example, one person had been identified as at very high risk of falls; there was no further risk assessment or care plan in place to show how staff were to support the person and to reduce the risks.

Medicines were not always managed safely within the service. We saw creams in people’s bedroom that did not have a name on or the label had been removed. This meant we could not be sure the cream had been prescribed for the person. Temperature checks were not being undertaken to ensure medicines were stored correctly.

We observed a number of concerns in relation to infection control. We saw some bedding was stained with faeces, one hand rail had faeces on, a wheelchair contained dried food and some carpets were badly stained.

Staffing levels within the service were not sufficient to meet people's needs. There was a lack of sufficient numbers of suitably experienced staff members on duty throughout our inspection. We asked the registered manager to address this as a matter of urgency.

People who used the service had access to various healthcare professionals. During our inspection we observed visits were undertaken by GP’s and district nurses.

We observed that people had a choice of meals. We saw that at both lunch and evening meal time’s people were eating different things. This showed various choices were available.

People’s privacy and dignity was not always respected. Bathrooms did not always provide sufficient privacy.

We observed interactions from staff members that were kind and caring.

Care plans were not person centred and did not contain sufficient information to direct staff on meeting the needs of people who used the service.

There was a lack of leadership within the service, particularly at times when the registered manager was not in the home. The deputy manager was unable to answer our questions on a number of occasions.

Following our inspection, on the 2 August 2017 we met with the provider and deputy manager to discuss some of the concerns we found during our inspection. The provider had taken immediate action to reduce some of the risks after our inspection such as hot water temperatures, privacy and dignity, cleanliness of the property, staffing levels and medication.

We carried out an unannounced inspection of Belvedere care home on the 7 and 8 June 2016.

Belvedere Care Home is registered to provide accommodation for up to 38 people who require personal care. Belvedere is situated in the centre of Accrington in Lancashire. At the time of the inspection there were 27 people accommodated in the home.

At the last inspection on 30 September 2014 we asked the provider to make improvements to the maintenance of records, staff training and to take action to ensure people’s best interests and wishes were considered and followed in a safe way. Following the inspection the provider sent us an action plan which set out what action they intended to take to improve the service. During this inspection, we found the necessary improvements had been made.

Prior to this inspection we had received some concerning information in relation to medicines management, infection control issues, inadequate lighting and lack of meal choice. We looked into these areas during the inspection.

We found the service to be in breach of two regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to a failure to assess prioritise and update necessary risk documentation to ensure the safe care and treatment of a person whose needs had changed considerably and failing to have adequate and effective infection control measures in place. You can see what action we told the registered provider to take at the back of the full version of the report.

We also made recommendations to the provider around failing to ensure premises were safe for intended use by having inadequate lighting and not storing equipment safely.

The registration requirements for the provider stated the home should have a registered manager in place. There was a registered manager in post on the day of our inspection. 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.

People using the service and their visitors talked about the service providing a safe caring environment. We found in most cases people were protected from risk without compromising their independence. Processes were in place to ensure the safety of people using the service, staff and visitors by means of environmental and individual risk assessments. However we found in one case essential individual risk assessments did not reflect the person’s current care needs.

Clear safeguarding policies and procedures were in place at the service and staff were provided with guidance and training in recognising the signs of abuse. This helped to ensure the staff team were fully aware of action they needed to take should they be concerned about a person’s welfare. Staff and the registered manager displayed appropriate knowledge about how to respond to and ensure any safeguarding issues had been notified to the relevant authorities.

We saw evidence that fire audits were up to date. People using the service had personal evacuation plans (PEEP) in place. Staff displayed a sound knowledge of processes to follow in the case of an emergency. However we noted two fire doors propped open with door stops. During the inspection the registered manager removed these and fitted electric door guards.

The service had a consistent number of care staff to support people throughout the day and night. This provided people with safe and personalised care and supported the operation of the service.

The service did not have a domestic cleaner at the time of inspection. This was having an impact infection control matters in the building. We found in some areas furniture was contaminated with dry food and carpets were stained. The service had an infection and prevention control policy

Prior to our visit we received some concerning information. We shared this information with the local authority in line with local safeguarding procedures. Following their initial investigation we visited the service. Two adult social care inspectors carried out this ‘responsive’ inspection. The focus of the inspection was to answer five key questions:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

During this inspection we spoke with four people using the service and with two visitors. We spoke with three care staff and the cook. We also spoke with the local authority and the police. We viewed records which included, two care plans and associated care records, safeguarding policies and procedures and staff rotas. We observed care practices.

We considered the evidence we had gathered under the outcomes. This is a summary of what we found:

• Is the service safe?

The plans of care contained a detailed past history, people's health and social care needs and any cultural or dietary needs. The care plans and risk assessments were reviewed regularly. The care plan process was lacking in screening and assessing people’s capacity to make their own choices and decisions and we found there had been no formal applications made under the Deprivation of Liberty Safeguards which would help ensure people’s safety and best interests were considered. It also indicated that staff may not understand the processes that should be followed to ensure people’s best interests and wishes were considered and followed in a safe way.

The care records identified if a person was at risk of harm from any hazard, such as from poor nutrition or restricted mobility. However, we found that although staff had completed theory training in moving and handling apart from one documented example they had not received practical training to support the theoretical input. This meant people may be at risk of injury due to inappropriate moving and handling.

We observed staff responding kindly to a person who was upset and agitated. However, staff had not been provided with training to help them respond to behaviour that challenges. Staff needed training to help keep themselves and others safe.

Staff had access to 'safeguarding adults' and 'whistle blowing' (reporting poor practice) procedures. Staff, who we spoke with, told us they received regular training to help them recognise and respond to any signs of abuse or neglect and would feel confident to speak out against poor practice if needed. However, we were concerned that a number of incidents and unexplained bruises had not been reported.

We found records such as staffing rotas and training records were not accurately maintained and were not stored securely.

• Is the service effective?

People told us they were happy with the staff team and they said there were enough staff to meet their needs. During our visit we observed people's requests for assistance were promptly responded to.

It was difficult to determine, due to the lack of records, whether staff received a range of appropriate training to keep them up to date and to give them the necessary skills and knowledge to look after people properly. However, from our discussions with staff, we noted there were gaps in the provision of training.

• Is the service caring?

People looked relaxed and had a friendly rapport with the staff. We saw that people looked clean and well cared for. A discussion with the person in charge and two care assistants showed they had a very good understanding of the needs of the people they were looking after.

People told us they were happy with the care they received and they were well looked after. They told us, “I am happy with the care. They look after me very well and it is all very good” and “I like it here, it’s all very good”. Relatives we spoke with made the following comments, “She has come on leaps and bounds since being here. The staff are really good” and “The staff know what they are doing, they are very nice and very kind. My wife is always nicely presented and always tells me how well she is being cared for. I come to see her twice a day so I see how good they are to everyone.”

• Is the service responsive?

People had access to a wide variety of hospital and other specialists such as speech and language therapists and routine professionals, for example opticians, podiatrists, dentists and district nurses. Records of these visiting professionals were maintained within the care plans of the individuals.

We found the home had sufficient experienced care and ancillary staff to meet people's current needs. We were told any shortfalls, due to sickness or leave, were covered by existing staff and additional staff had also been provided to accompany people to appointments. This ensured people were looked after by staff who knew them.

• Is the service well-led?

The manager, who was also the owner, was registered with Care Quality Commission (CQC) and responsible for the day to management of this home. Staff told us they were supported and were able to discuss their day to day concerns with the manager or deputy manager.

We were concerned about the day to day management of Belvedere Care Home as the registered manager and the deputy manager were currently absent from the home. However, we found experienced staff were working additional hours to ensure the home was managed safely.

We spoke with four people using the service and two visitors. They told us, “Yes I am happy here”. “They all know me and what I like”. “I have been here a long time and I don’t want to be anywhere else”.

People's care records contained enough information to show how they were to be supported and cared for. People told us they were well looked after and that they felt safe.

The medication system was safe and people told us they received their medicines when they needed them.

Enough suitably skilled staff were on duty to meet people’s needs. One person using the service told us, “They are all very nice, they are all very good”.

An effective complaints procedure was in place and people knew how to make a complaint.

We carried out this inspection after receiving information there were concerns about staffing levels within the home.

We spoke with four people who used the service and they told us that they were happy with the care and support they received. People made positive comments about the staff. Comments included:

"Staff are lovely, very kind and helpful here is nothing negative I can say about the staff. They are wonderful."

"There are enough staff about if I need one. We seldom have to wait for help including during the night"

"We're very well looked after here.There isn't a member of staff that you couldn't say was anything but kind and helpful."

We spoke with one relative who told us; "The staff are good. They are very patient. The care is excellent. We're kept involved."

During our visit we observed positive interactions between staff and people who lived at Belvedere Care Home . We saw that staff spoke at a pace which met people's needs and engaged with people in a calm and patient way, which allowed people time to explain what they wanted or where they wanted to go. We spoke with three members of staff who told us there were enough staff to meet people's needs and they had plenty of opportunities for training.

The people we spoke with told us that they were very happy with the care and support they received and the staff were polite and easy to communicate with. One relative told us, “My Mum enjoys herself here.”

We spoke with four people who used the service and three relatives. People told us that they found the staff were kind, friendly and they knew how to assist them. They said “It is nice here, they are a good bunch”, “We get on really well and they are always giving me a hand” and “I’m asked what I want to do and that”. The relatives we spoke with thought the staff appropriately supported the individuals.

Those who were able said they did not have to wait long for the call bell to be answered for assistance from the staff. Staff had knowledge of privacy, dignity, independence and human rights. For example, how to maintain privacy and dignity when assisting with personal care and promoting independence with mobilising around the home. They showed an understanding of the need to encourage people to be involved in their care. For example, staff recognised the need to explain tasks to people before assisting them. Other comments made were, "I love some of the carers. They try and do a good job." "Staff have a good relationship with residents." "Staff are good and speak kindly."

As reflected in relatives' comments, it would be beneficial to have occasional residents and relatives meeting with the management to jointly improve the life of residents.

Feedback from residents was very good; comments regarding the staff working in the home included "nice people", " very caring and always treat me alright", "find time to listen" and "excellent care provided". "help me to retain as much of my independence as I possibly can".

Lots of different types of activities were arranged, both in the home and out in the community. We spoke with the resident who chairs the Residents' Forum who informed us that the monthly meeting are a time when residents can put forward their ideas and these are later taken to the manager for agreement.

Social Workers who have been involved in helping people to find accommodation at the home have provided us with positive feed back including specific comments about the high standard of commitment and caring they have witnessed from the staff and manager

The monitoring team from the Local Authority have visited and they found that the examples where the information gathered should be recorded in a more consistent way so that it can be used to decide if the home is suitable for the resident and will meet the resident's assessed needs.

In discussion with the manager and the deputy manager we were informed that initial enquiries were recorded and followed up by a visit to the individual, either in their own home or, more commonly, in hospital, to complete a detailed assessment of their needs. The manager liaises closely with family members and any health care professionals involved with the prospective resident. This helped the manager to build up a full picture of the person's needs. The assessment included personal and health care needs, as well as social care and behavioural needs. The manager generally conducted pre-admission assessments.