Inspection on 10/02/06 for Bilney Hall

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bilney Hall 26/02/07

Bilney Hall 24/10/05

Bilney Hall 01/02/05

Bilney Hall 13/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Firstlings

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bilney Hall Bilney Hall East Bilney Dereham Norfolk NR20 4AL Lead Inspector Mrs Geraldine Allen Unannounced Inspection 10th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bilney Hall Address Bilney Hall East Bilney Dereham Norfolk NR20 4AL 01842 878240 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.manorcourtcare.co.uk Manorcourt Care (Norfolk) Ltd Ms Valerie Jeanette Fullerton Care Home 31 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (12) of places Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 Brief Description of the Service: Bilney Hall is a care home providing personal care and accommodation for up to 31 older people, 19 of whom may have a Dementia. The home also provides day care services to the local community. Bilney Hall is owned by ManorCourt Care (Norfolk) Ltd`, which has other homes and resources within Norfolk. The home is situated in the village of East Bilney, between Fakenham and East Dereham. Bilney Hall is a converted manor house with a purpose built extension added, and is set in extensive grounds. The grounds include walled gardens and lawn areas and views are afforded across the local countryside. Accommodation is provided in 25 single bedrooms and 2 shared bedrooms. Twenty-one of the bedrooms have en-suite facilities. There is ample communal space, allowing service users choice about where and how they spend their day. There is a passenger lift providing access to all levels. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 10 February 2006. Not all of the National Minimum Standards were inspected on this occasion and, where a standard has been inspected, the complete range of sub elements, as set out in the National Minimum Standards, may not have been assessed. There were 30 residents living at the home on the day of inspection. At the time of this inspection, the Commission was involved in an assessment scheme with Age Concern, looking at the benefits of including people with experience of care (Expert by Experience), either for themselves or a relative, in the inspection process. Although this inspection was unannounced, prior agreement had been received from the recently appointed manager, Mrs Carlton, that an Expert by Experience and representative from Age Concern would be present at this inspection. As stated above, since the last inspection a new manager, Mrs Elizabeth Carlton, has been appointed. The process to register Mrs Carlton with the Commission is due to start soon. Information was obtained through discussing issues with Mrs Carlton, looking at records and watching staff as they went about their duties. A tour of the building was also done. The Expert by Experience and Age Concern representative spent time talking with residents and staff in the residents’ lounges. The inspection found that good progress has been made since the last inspection. Residents are well cared for by experienced and caring staff in very pleasant surroundings. What the service does well: What has improved since the last inspection? Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 6 The assessment carried out before a resident enters the home has been improved. Information is obtained from the resident and their carers to make sure the home can meet their needs. All this information is properly recorded. An improvement has been made in the way newly recruited staff work at the home before Criminal Records Bureau (CRB) checks have been received. This is to make sure that residents are protected from possible abuse. The records that show the training being done by staff when they are new to the home has improved since the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home undertakes a pre-admission assessment in all cases to ensure the home can meet the residents’ needs. EVIDENCE: A requirement was made at the last inspection regarding the pre-admission process and records to be kept about this process. This requirement was met. Mrs Carlton confirmed that pre-admission assessments are completed in all cases and the 2 most recent were seen. The pre-admission procedure includes seeking the views of prospective residents and their carers, including health professionals. Mrs Carlton described the changes she intends to make to the process to ensure the needs of residents with dementia are better assessed. Mrs Carlton intends to liaise with another of the groups homes that provides dementia care to ensure all relevant information is obtained and recorded and needs identified. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 Care plans are in place but the contents need to be improved and developed to provide better guidance for staff. The home has good policies and procedures in place regarding the control, administration and recording of medicines. Residents are treated with respect. EVIDENCE: A requirement was made at the inspection on 24 October 2005, regarding the lack of clarity and guidance within care plans. This requirement has not been met although changes are being effected. Mrs Carlton has developed new daily handover records that specify particular needs for each resident and give clear guidance to staff. For residential clients, care plans are now kept in the residents’ own bedroom, where they have full access to records kept about themselves. Care plans for residents in the Dibben Wing are kept accessible for staff. Mrs Carlton described her plans to improve the standard of recording and information contained within the care plans. She intends to introduce a more scheduled care plan review process and recognises the need for good staff Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 10 training to ensure the improved practices are complied with. The requirement made at the last inspection has been repeated. See requirements. The arrangements for the control, administration and recording of medicines were inspected. A member of staff was observed dispensing medicines at lunchtime and operated in accordance with good, safe practice. Records of administration were seen and were up to date and properly completed. The home had controlled medicines on the premises at the time of inspection. These were appropriately stored and records were well kept. The record of medicines returned to the pharmacy was not available for inspection, as it had been sent to the pharmacist the day before, along with unused medicines. The home has a homely remedies list of medicines that has been approved and signed by the visiting GP. The refrigerator used for storing medicines was seen and operating temperatures were within normal limits. Two members of staff have attended certified medicines training but Mrs Carlton was unclear about another designated senior staff. Mrs Carlton intends to undertake an audit of staff competence and also the practices followed. See recommendations. The Expert by Experience spent time speaking with residents and fed back observations. Reference was made to comments made by residents, who felt that staff were caring and friendly. Staff had taken care to ensure the residents’ clothes were smart and clean, helping to ensure their dignity. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive a varied and nutritious diet. EVIDENCE: A recommendation was made at the last inspection regarding the provision of menus at the dining table for residents. Mrs Carlton stated that menus have now been reviewed. A laminated copy of the menus will be available in the residents rooms to act as a reminder. Choices of food are provided to residents in the Dibben Wing at the point of serving. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are protected from abuse by good recruitment practice. EVIDENCE: A requirement was made at the last inspection regarding staff working unsupervised pending full Criminal Records Bureau (CRB) disclosure. Mrs Carlton described the practices now being followed. These include internet applications and disclosure requests being made earlier in the recruitment process. No care staff are able to commence employment until CRB disclosures have been received. Non-care staff are able to commence work pending receipt of the disclosure but work fully supervised. Staff files for 3 overseas staff who have recently been appointed were seen. These showed very good procedures in place to ensure the good conduct and integrity of these staff. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23 & 26 The home is well maintained and the décor of a good standard. There are sufficient and suitable toilet and bathing facilities. Residents’ bedrooms are homely and highly personalised. The home was clean, hygienic and tidy. EVIDENCE: A brief tour of the building took place. This showed that the home was being well maintained. The décor was appropriate and clean. Refurbishments of some parts of the old hall were continuing to a good standard. A recommendation was made at the last inspection regarding the use of a bathroom in the Dibben wing to store equipment and aids. This bathroom was seen and was more welcoming following the removal of the items. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 14 The Expert by Experience and Age Concern representative were invited by some residents to view their bedrooms. They reported that these bedrooms had a homely feel and contained plenty of personal possessions. The home was clean and tidy on the day of inspection. There was an unpleasant odour outside a bedroom on the first floor of the Dibben Wing early in the inspection but this had dissipated later in the day. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 The home employs sufficient staff hours to meet the needs of residents. However, there are concerns about the number of staff working excessively long shifts as a matter of course and the effect this may have on their competence. The home operates robust recruitment practices that protect residents. Staff receive training to ensure they are competent to fulfil their role. EVIDENCE: A copy of the staff rota for the week of inspection was provided. Calculations were made and showed that the home provides sufficient care staff hours to meet the needs of the residents. It was noted that, excluding night staff, a total of 15 care shifts were of 10.5 hours duration and 9 care shifts were of 14.5 hours duration. On some days, 4 of the 6 day care staff were working excessively long hours. The Commission has concerns that this practice has implications for the competence of staff, their health and well-being and also the health and safety of residents and other staff. See requirements. During the course of this inspection, staff were not seen engaged in meaningful activity with residents beyond assisting them in personal care. The rota does not show a designated activity organiser. A person to fulfil this function would be beneficial to residents as they could develop a programme of events that are relevant to the needs of the residents and could operate in co-operation Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 16 with the “Friends”, who are involved in fund raising and the purchase of such amenities. See recommendations. Mrs Carlton provided details of the recruitment procedure and the files of 3 staff recruited from overseas were seen. The files were in very good order and demonstrated robust procedures that protected residents. Mrs Carlton spoke about her concerns to ensure the staff were able to converse well and how she set about checking this. The information provided by the recruitment agency was extensive and well presented. A recommendation was made at the last inspection to ensure that staff induction was properly recorded. This has been met and the induction and foundation training records for the recently appointed staff were seen. Mrs Carlton described her review of staff training at the home and has identified training needs that are being met. For example, further fire training has been arranged and the head of care was scheduled to attend care planning and key working training. First Aid and basic life support by St John’s had also been arranged. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37 & 38 A person who is qualified and competent manages the home. The home seeks the views of residents and their relatives and visitors to the home. Generally, records are well maintained and up to date. The health, safety and welfare of residents and visitors to the home are safeguarded by good practice in respect of accident records and analysis. EVIDENCE: Mrs Carlton has recently been appointed as manager at this home and is due to commence the registration process shortly. Mrs Carlton is an experienced manager and is well qualified. The home has a quality assurance process in place. Mrs Carlton stated that new sets of questionnaires are ready to be distributed to residents and visitors. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 18 Staff have also been included in the process and questionnaires distributed to them prior to this inspection. Mrs Carlton described how she will collate the information once it is returned and also the development of an action plan on the issues raised. A copy of the results of the summary and action plan was requested to be sent to the Commission once the process is complete. A requirement was made at the last inspection regarding the advising of notifiable occurrences to the Commission. This has been met. Apart from the issues already raised about care plans (see standard 7), all other records seen were in good order and up to date. Entries were legible and coherent. Records were stored appropriately, with care plans now kept in resident’s bedrooms in the old hall and confidential records kept in locked cabinets in the managers office. The accident records for the home were seen and good practice noted. In addition to the full record, a monthly accident log is kept that informs the accident audit process. This allows for a speedy analysis to take place so that patterns can be identified and any remedial action or acquisition of aids made in a timely way. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 x 3 X 3 X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 3 3 Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that care plans are kept up to date and include clear direction for staff to ensure the care provided is appropriate to the resident. This requirement is repeated from the last inspection. Timescale for action 10/05/06 2 OP27 18 (1)(a) The registered person must 01/05/06 review the hours worked by staff and how staff hours are employed to ensure staff do not place residents and others at risk by working excessively long shift hours. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that all staff receive certified training regarding the safe use of medicines and that a regular DS0000045248.V283513.R01.S.doc Version 5.1 Page 21 Bilney Hall 2 OP27 audit of competence is undertaken. It is recommended that an activities organiser is employed during the day to ensure that residents are able to take part in arranged, meaningful activity if they wish. Bilney Hall DS0000045248.V283513.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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