There was a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (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 comprehensive inspection on 17 August 2017, we found that improvements were required in relation to mental capacity assessments, staff lack of understanding of safeguarding procedures, the environment required improvements and staff training and induction was not robust. We also identified that people’s records were not always kept up to date and there were insufficient audits taking place. At the latest inspection we found that this had improved although there were some areas that we asked the provider to address that related to some aspects of the environment. After the inspection the provider sent us evidence to show that these areas had now been addressed.

Staff understood what they needed to do to protect people from abuse. People told us that they felt safe with staff and we found that there were sufficient numbers of staff to support people. People’s medicines were managed in a safe way. Risks to people care was managed well by staff. Staff had a good understanding of infection control. The service was clean and well organised.

Staff understood and knew how to apply legislation that supported people to consent to treatment. Where restrictions were in place this was in line with appropriate guidelines.

There was detailed information in care plans for staff to follow. However, there was not always detailed information that related to end of life care planning. Although activities took place on the day of the inspection these needed to be more person-centred. More outings were needed for people. Staff did not always know what people’s interests and hobbies were. We have made recommendations around all of this.

There were systems in place to regularly assess and monitor the quality of the service the service provided however this was not always effective. We identified some shortfalls that were addressed soon after the inspection. We have made a recommendation around this.

Recruitment practices were safe and relevant checks had been completed before staff commenced work. Accidents and incidents were acted upon and measures were in place to reduce the risks. In an emergency such as a fire or a flood staff understood what they needed to do to ensure people were evacuated safely.

Staff were trained and supervised to ensure that appropriate care was delivered. People were supported to have access to healthcare services and healthcare professionals were involved in the regular monitoring of their health.

The environment suited the needs of people that lived at the service. Assessments of people’s needs were undertaken before they moved in to the service. Staff worked well across the service to ensure good delivery of care.

Staff were kind, caring and attentive to people’s needs. People were treated with respect and dignity by staff. People were encouraged to be involved in their care delivery. Staff supported people to live independent lives. People were supported to practice their faiths and visitors were always welcomed to the service.

People were encouraged to voice their concerns or complaints. Complaints were investigated and responded to. The provider actively sought, encouraged and supported people's involvement in the improvement of the home. Staff were encouraged to contribute to the improvement of the service and staff felt valued.

The management and leadership of the service were described as good and very supportive. Staff worked in partnership with external organisations.

Services that provide health and social care to people are required to inform the Care Quality Commission (

This inspection took place on 17 August 2017. The visit was unannounced.

Bellsgrove Care Home provides residential care for a maximum of 15 people. Some people receiving the service were living with dementia. On the day of the inspection there were 15 people living at the service.

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 registered manager was also the provider. Throughout this report we refer to them as the registered provider. The registered manager was on holiday during the inspection and the trainee manager, who is a relative of the registered manager, was in day to day charge.

Everyone who lived at Bellsgrove, their relatives and healthcare professionals all commented very positively about the care at this home. However, although we found that people were cared for by dedicated staff improvements were needed in the running of the service.

People were not protected against the risks of potential abuse because staff were not aware of their responsibilities in how to safeguard people and did not receive safeguarding training in their induction.

People did not have PRN protocols in place for their ‘as required’ medication. This meant that staff might not have the information about when someone might require a medicine or what the maximum dose was. Medicines audits were not being carried out regularly to ensure good practices were being followed.

Staff did not work in accordance with the Mental Capacity Act 2005 (MCA). MCA assessments had not been completed for specific decisions and staff were unaware of the principles of the MCA. This was the same as at the previous inspection.

People were receiving care from staff who had not been provided with induction training which ensured staff were prepared for their role. Staff were also not provided with on-going training to ensure there competence was maintained

People and their relatives were concerned that the provider’s plans to refurbish the whole of the ground floor had not happened. The living room carpet and chairs were dirty and aged and there were torn blinds in the conservatory.

Contemporaneous records of peoples care, and decisions being made in relation to their care were not being kept. There were no audit systems in place to monitor and improve the quality of care being provided at the service. This meant the registered provider was unable identify shortfalls and make improvements.

People felt safe and their care records contained up to date risk assessments to guide staff in how to protect people from risks whilst enabling them to remain independent. The provider followed safe recruitment practices. People were supported by sufficient staff to meet their individual needs and medicines were administered safely.

People’s nutrition and hydration needs and preferences were met. People’s health care needs were monitored and any changes in their health or well-being prompted a referral to their GP, district nurse, tissue viability nurse, community mental health team, or other health care professionals.

Staff were caring and knew people well. People were encouraged to be independent. Staff promoted people’s privacy and dignity, and people were able to have a say in the running of their home.

Care plans were detailed and contained information on people’s lifestyles and preferences. They included details on people’s routines and what support people liked to receive. People’s needs were assessed and their care was regularly reviewed.

People had access to a range of activities and were able to choose what activities they took part in. People and their relatives knew how to make a complaint and raise concerns. Relatives and fr

Bellsgrove Care Home provides personal care and support for a maximum of 15 older people, some of whom may be living with dementia. Accommodation is set over three floors all of which have access via stairs or a lift. On the day of our inspection 15 people were living in the home.

This was an unannounced inspection that took place on 7 September 2016.

The home 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 and associated Regulations about how the service is run. The registered manager assisted us with our inspection on the day.

In the event of an emergency where the home would have to close, the registered manager had not considered how people’s care would be provided. There was no contingency or emergency planning process in place so staff may not be able to provide effective care in such a situation.

Staff had not always completed decision specific assessments in relation to the Mental Capacity Act 2005, although applications where people’s liberty was being restricted had been made. Staff were heard to obtain people’s consent before they supported them.

There was a good atmosphere in the home where people and staff interacted in an easy-going manner. People and relatives were extremely happy with the care provided and they were made to feel welcome when they visited. Staff supported people to take part in various activities and staff were attentive to people to ensure they were involved with anything that was going on.

Staff followed correct and appropriate procedures in administering medicines and medicines were stored safely.

Care was provided to people by staff who were trained and received relevant support from their manager. This included regular supervisions and appraisals. Staff told us they felt valued by the registered manager and enjoyed working in the home.

Care plans contained information to guide staff on how someone wished to be cared for. Information included detail around people’s mobility, food and personal care needs. Where people had risks identified guidance was in place for staff to help reduce these risks.

Quality assurance checks were carried out by staff to help ensure the environment was a safe place for people to live and they received a good quality of care. Staff were involved in the running of the home as regular staff meetings were held. People were asked for their views about all aspects of their care and could make their own decisions. We received some good feedback about the home.

There were a sufficient number of staff to care for people. Safe recruitment practices were followed, which meant the provider endeavoured to employ staff who were suitable to work in the home. Staff were able to evidence to us they knew the procedures to follow should they have any concerns about abuse or someone being harmed.

People had care responsive to their needs and staff knew people extremely well. People were provided with a choice of meals each day and those who had dietary requirements received appropriate food.

Staff maintained people’s health and ensured good access to healthcare professionals when needed. For example, the doctor, occupational therapist or district nurse.

People knew how to make a complaint if they felt the need to. They told us any concerns they raised were dealt with immediately by the registered manager.

There was an open positive culture within the home and it was evident the registered manager was respected by staff. The registered manager had a good management oversight and was keen to improve the quality of care provided. We raised some issues we found with the registered manager during the inspection. These related to the environment, cleanliness, contingency plan and medicines storage. Before we left the insp

This was a follow up inspection that related to respecting and involving people who used the service and the care records kept by the service for people.

We found that staff interacted with people during our inspection. We saw that people were involved in separate activities and staff engaged with them individually.

We spoke with one relative of a person who used the service. They told us that they felt staff engaged with their family member regularly. They told us that the service held events that were popular with people. They told us that this included a choir coming to the service.

We found that the records were up to date with daily care information on each person who used the service. We also found that each person’s file had been updated with any visits from Health Care professionals.

We found that people who used the service and their relatives were involved in the planning of their care. We saw that staff treated people with respect and dignity. However the service did not have meetings with all of the residents and their family members to discuss how the home should be run.

We could not speak with most people as they had complex needs. The relatives told us that the care that was provided to people was good. We looked at two care plans and saw that people’s needs had been identified and risks assessments had been completed.

All the staff we spoke with were able to tell us about how to safeguard vulnerable adults and the types of abuse to look out for. They were also able to tell us who the local safeguarding team were and how to contact them if necessary.

We found that there were suitable amounts of qualified staff that met the needs of people who used the service. Staff told us that there were always enough staff on duty and that staff sickness was always suitably covered.

The provider was able to show us that all of the staff had received up to date training in all of the mandatory courses required by the service. Staff told us that they felt supported and that they could speak to their manager if they had any concerns.

We were unable to speak to most people using the service because they had complex needs which meant they were not able to tell us their experiences.

We spoke to two people who were using the service and two relatives during our inspection. One person told us that they didn’t go out much. They told us that they felt the place was like their own home and felt very comfortable. Another person told us that activities did not happen much but they enjoyed going out when they could.

One relative told us that they staff provided “Brilliant care” and they were very happy with the care that they received. They said that nothing was too much for the staff when it came to the care for their relative. Another person told us that they knew that their relative was well looked after and had never had any concerns about their treatment at the service.