Bilney Hall

Updated 24 February 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 20 January 2022 and was announced. We gave the service 24 hours notice of the inspection.

Updated 24 February 2022

About the service

Bilney Hall is a residential care home providing personal and nursing care to 62 people aged 65 and over at the time of the inspection. The service can support up to 63 people mostly living with a diagnosis of dementia.

People’s experience of using this service and what we found

The service accommodated people with a wide range of needs but predominantly those living with dementia. Accommodation was flexible and spacious. The layout of the building was taken into account when rostering staff. Staffing levels had improved and people received consistent support from regular staff. Agency staff had not been used for more than five months.

There was good communication, team work and management oversight. Staff told us the service had vastly improved since the registered manager had arrived and told us they received the training and support they needed to work effectively.

Although staffing was assessed to be sufficient, people’s experiences varied with some expressing concern about staff’s responsiveness. Relatives also commented they could not always find staff at busier times of the day. We have made a recommendation about this.

Risks to people’s safety were mostly well managed but we identified several environmental issues., These were rectified straight away which gave us confidence in the service. Risks assessments were in place and there were control measures in place to actively reduce risk. Audits were completed regularly and there was an established programme of refurbishment and replacement. The service had recently spent a lot of money on the service to bring it up to the required standards. We found overall the service was very clean with no odours and observed staff using personal protective equipment when supporting people. Staff received regular health and safety training and training in infection control, both were covered as part of staff’s initial induction. There were a few concerns about cleanliness, in relation to chips in paintwork and wear and tear which could harbour infection but there was a plan in place to address this.

Staff recruitment processes were robust. This helped to ensure only suitable staff were employed. Staff were supported in their employment, completing a detailed induction and received ongoing training and development, supervision and annual appraisal.

Medicines were given safely and as required and people’s health care needs were regularly monitored. The registered manager kept a detailed clinical risk register which indicated any concerns about people using the service. This could be related to a recent fall, unplanned weight loss, frail tissue viability or current infection. People were discussed at a daily head of department meeting to help ensure all actions were being taken and all key staff were aware of changes in people’s health.

People benefited from a nice environment suited to their needs. We found however signage was poor and the building was difficult to navigate. The service has since addressed this. Social activities were planned, and there were designated activity coordinators, who provided regular activity. The scope of activity was being improved upon, but all staff needed to recognise the importance of activities of daily living and promoted people to engage across the day.

Staff were observed to be caring and had good interpersonal skills and had a good understanding of dementia and how it might impact on the person. Care plans were sufficiently detailed, but we felt they could be more descriptive in terms of people’s preferred routines and how staff might reduce people’s anxiety around their routines. We have made a recommendation about care plans.

The registered manager told us they were well supported by their regional manager and were able to influence the budget and ask for additional resources as they saw fit. They described the regional manager as responsive which helped them effectively manage the service. The registered manager was a qualified nurse, very experienced in care and a good communicator. They knew people’s needs extremely well and ensured the service was well planned and staff sufficiently supported. We met the regional manager and discussed the schedule of audits which were top heavy and did not sufficiently focus on people’s experiences. The service did an annual quality assurance survey but the return of these was low and therefore unreliable. This year forms had been amended to make the questions easier, but surveys were not appropriate for everyone using the service. The regional manager said they were developing a dementia strategy, and this would be adopted by the organisation. We have made a recommendation about audits being more specific to the needs of people using the service and have suggested accreditation in dementia and end of life care would improve outcomes for people.

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.

Rating at last inspection

The last rating for this service was Good. The last report was published, (15 March 2017.)

Why we inspected

This was a planned inspection based on the previous rating.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk