Bilton Hall Nursing Home

Bilton Hall Nursing Home is a residential care home providing accommodation for people who require nursing or personal care to up to 60 people. The service provides support to people living with dementia, people over the age of 65 and people under the age of 65. At the time of our inspection there were 44 people using the service. The building is adapted into three wings, each with separate facilities. One of the wings specialises in providing care to people living with dementia.

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

People did not receive safe care and support as staff were not reliably trained to support their required needs.

Risk assessments were in place and considered risks and how to minimise them. Medication was administered safely, documentation for topical medicines was not always in place. We have made a recommendation about this. Infection prevention and control practices had improved. Staff were recruited safely, and lessons were learnt when things went wrong.

People were afforded choice and control over their care and there were activities available. Information was available in a variety of formats and care planning was to a good standard.

People were included in decisions about their care and the provider had systems in place to work with other organisations. There was a new manager in post who had a plan to improve the standard of care and systems to 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.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 December 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of all the regulations found on the last inspection.

Why we inspected

We received concerns in relation to the management of catheter care and the standard of food at the service. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed and remains requires improvement, based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well led sections of this full report.

The provided already had plans in place to retrain staff in regard to catheter care and a new general manager was improving the standard of care and culture within the service

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to staff training and poor knowledge on catheter care at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Bilton Hall Nursing Home is a nursing home providing personal and nursing care to 50 people aged 65 and over at the time of the inspection. The service can support up to 60 people. Bilton Hall Nursing Home is a single adapted building with two wings. One of the wings specialises in providing care to people living with dementia.

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

People were not safely protected from the risk of infection transmission due to the practices within the home.

Governance oversight and management systems did not identify issues which we found on inspection.

Risk assessments were not always in place to make sure people had support to minimise the risk of harm. Care plans did not always contain up to date or accurate information.

Medication was not always managed safely. Records did not demonstrate people received the correct creams and ointments. One person received covert medication without the correct checks and legal safeguards in place.

People were protected from the risk of abuse or neglect. Staff were safely recruited and there were enough staff to meet people’s needs. The registered manager learnt lessons when things went wrong.

People told us they were supported to live empowered lives with choice and control. The service worked in partnership with other agencies and had a duty of candour when things went wrong.

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.

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

Rating at last inspection

The last rating for this service was good (published 8 June 2018).

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding incidents and unsubmitted notifications. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to infection prevention and control measures and management oversight at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Bilton Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Bilton Hall provides nursing care for up to 60 older people some of whom are living with dementia. When we inspected there were 50 people living at the home. Accommodation is provided over two floors with a dementia care unit known as the 'Butterfly Unit' situated on the first floor. At our last inspection we rated the service good. There was a breach of Regulation 10 of the Health and Social Care Act (Regulated Activities) 2014, because arrangements in place to assist people to bathe or shower did not promote people’s privacy and dignity.

At this inspection we found improvements had been made and the service was now meeting legal requirements. The rating remained good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Appropriate systems were in place to ensure safeguarding concerns were dealt with appropriately. Assessments of risks associated with people's care and support were completed and steps taken to minimise the likelihood of any harm. Lessons were learnt from when accidents or incidents occurred.

Regular checks were carried out to ensure the premises were kept in a good state of cleanliness and repair. Adaptations had been made to the environment to help orientate people to find their way around the home and we were told that people were supported to access the outside space when they chose.

The provider recruited staff safely. Staffing levels were kept under review to make sure enough staff were available to provide people with appropriate, timely assistance.

While more detailed guidance was needed around the use of medicines in specific situations appropriate systems were in place to protect people against the risks associated with medicines.

Staff received appropriate training and support to provide them with the skills, knowledge and supervision they needed to carry out their roles.

People were supported to maintain good health and nutrition in partnership with other healthcare professionals when needed.

There were some occasional gaps in monitoring documentation, but overall records were well completed and showed that care was provided in line with people's needs and wishes. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People enjoyed positive relationships with the staff and they were treated with respect and kindness.

People were involved in planning how they wanted their care and support delivered. Staff knew people’s individual preferences and there were opportunities for people to get involved in activities.

The provider responded to complaints appropriately and people told us they felt confident any concerns would be addressed.

Effective management systems were in place to promote people’s wellbeing and drive continuous improvement. This included internal audits and also provider audits which provided positive feedback about the service. People and their relatives were included in the development of the service through surveys and meetings.

Staff and people using the service; their relatives and representatives expressed confidence in the registered manager’s abilities to provide good quality care. Staff reported a supportive leadership with the emphasis on good team work.

Further information is in the detailed findings below.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We felt confident the provider had addressed the issues raised at the previous inspection which meant people who live at the service were at reduced risk of infection and live in an environment which was clean and hygienic. We found that improvements had been made and the areas in the home previously identified had been cleaned thoroughly and were now clean. Infection control auditing was in now in place and action had been taken to address issues that were found. The laundry had been refurbished which reduced the risk of cross contamination.

Is the service well led?

The previous inspection identified although the service had a range of quality assurance systems they were not tailored to the needs of the client group. Since the previous inspection the manager had produced a simplified, bullet point version of the dementia strategy which she discussed with staff during supervision and staff meetings. The manager had also met with relatives with the aim to gather views about the development of the specialist dementia care unit. The manager also told us of the links she has made with other agencies providing services for people living with dementia in the local area and the plans to work collaboratively with them. This will help enhance the support people receive and enhance staff skills and knowledge.

Below is a summary of what we found. The summary describes what people using the service, their relatives 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.

Safe

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continuously improve.

The home had proper policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The manager told us about applications that had been submitted. We found staff had received training with regard to the Mental capacity Act 2005 and Deprivation of Liberty safeguards. Some staff we spoke with were unclear about their understanding of MCA and DoLS and the provider may consider re visiting this with staff.

People were at risk of infection because there were areas of the home where good infection control guidance had not been followed. More effective auditing and monitoring would help reduce this risk.

When people were identified as being at risk, their care plans showed the actions that would be required to manage these risks. These included appropriate referrals to other health and social care professionals such as dentists, opticians, occupational therapy and dieticians.

Effective

People's health and care needs were assessed with them, and they were involved in developing their plans of care. Care plans provided sufficient information which explained how each person needed to be safely supported by staff. We saw that in the main people's wishes and preferences had been clearly recorded, so that they were cared for in the way they had chosen. However, those people living with dementia would benefit from care planning which was more person centred and reflected current good practice.

Caring.

We saw staff were kind and respectful when speaking with or supporting people.

We saw that staff acted in a kind and respectful way People looked well cared for and appeared at ease with staff. The home had a relaxed and comfortable atmosphere.

People told us they were supported by kind and attentive staff. One person commented 'The care here is very good, I'm very satisfied'.

Another person said in response to the improvements to their health 'I put it down to the excellent care here and the lovely staff, I can't knock them; they've been brilliant, just pushing me enough to keep me going'.

Responsive.

People using the service, their relatives and other professionals involved with the service completed an annual survey. This enabled the manager to address any shortfalls or concerns.

People we spoke with knew how to make a complaint if they were unhappy.

The provider had sought specialist advice in order to improve services provided to people living with dementia and had implemented recommendations made.

We saw a staff team that acted professionally and responded appropriately to people's care needs. People were being assisted promptly and we saw that the staff had time to spend socialising and engaging with people. For example we observed one person appeared to be quite warm and the activities coordinator called for a carer to change this person into something cooler so they were comfortable.

Well led.

While systems to audit and monitor the service were in place, they were not sufficiently effective to assess and manage risks to the health, safety and welfare of people who used the service and others.

The provider had procedures in place for reporting any adverse events to Care Quality Commission (CQC) and other organisations such as safeguarding, police, deprivation of liberty, and the health protection agency. Our records showed that the provider had appropriately submitted notifications to CQC about incidents that affected people who used services.

We observed staff, spoke with them and looked at records. We were unable to assure ourselves that people's needs were being met as the records were unclear and staff were unable to provide us with consistent information about how people were cared for safely.

We used a number of different methods to help us understand the experiences of people using the service including talking to people who lived at the service, staff, visiting relatives and observing the care provided. We spent time with people using the service and we observed staff being friendly and warm towards people.

We observed that staff and people using the service had positive relationships and people appeared relaxed and comfortable with their surroundings; with staff and the activities they were engaged in. We saw that staff spoke at a pace which met people's needs and engaged with people in a calm and patient way. One person said 'The staff are lovely, they look after us here really well.' Another person told us 'Staff are fantastic, I have all I need here.' The relative we spoke with told us 'The nursing care is excellent and they communicate with me really well.'

We felt that staff would benefit from further training in order to improve the care and support people living on the dementia unit received.

Improved monitoring and auditing arrangements would ensure consistency in relation to the safety of the recording and administration of medicines.

There were sufficient staff available; we saw people being assisted promptly and we saw that staff had time to spend socialising and engaging with people.

The provider had effective system in place to regularly assess and monitor the quality of service that people received.