Bilton Hall Nursing Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified a new breach of regulation in respect of good governance. Some issues with documenting and recording of information were identified and these had not been highlighted by the provider’s governance procedures. A new management team was in place and the provider had implemented senior managers into the service to support with improvements. Further work was needed to ensure improvements continued and good practice was embedded and sustained. Staff spoke positively about the management team. Leaders were open and transparent during the assessment process and were responsive to our feedback.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Most feedback from staff about the leadership of the service was positive. Staff spoke about improvements now there was a new deputy manager. They also spoke positively about the interim manager in post at the time of the assessment. Staff were given responsibility with roles, such as becoming 'champions' in different areas of practice. They were also supported to complete quality assurance audits to help understand the quality of care required.

The provider had implemented senior managers into the service to support with improvements. There was evidence that they promoted the provider's visions and values. We observed the management team leading by example, showing and demonstrating good practice to staff. The leaders were open and transparent during the assessment process and understood that there were ongoing improvements which needed to be made. The leaders were responsive to assessment feedback and resolved issues immediately where they were able to do so.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

A new management team was in place and leaders confirmed several roles had recently been recruited into. Some areas of good practice were recently introduced to the service and the provider’s quality manager had had recent positive involvement. The improvements and good practice still needed to become embedded within the service and the new staff team. Action plans needed to continue to be followed, and the changes sustained, to evidence they would be maintained.

Some comprehensive audits were in place. These identified issues and action plans were then created. However, actions were not always signed off by leaders to show they had reviewed and confirmed when actions were completed. Some issues with recording were identified and these had not been highlighted by the provider’s governance procedures. For example, records around repositioning, emollient creams, thickening agents, staff employment histories and fire drills.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.