Inspection on 24/10/05 for Bilney Hall

This inspection was carried out on 24th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bilney Hall 26/02/07

Bilney Hall 10/02/06

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 Announced Inspection 24th October 2005 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.V256334.R01.S.doc Version 5.0 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.V256334.R01.S.doc Version 5.0 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.V256334.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 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.V256334.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place on Monday 24th October 2005. Not all of the National Minimum Standards were inspected on this occasion. Those standards not inspected will be reviewed at a future inspection. Since the last inspection a new manager, Mrs Fullerton, had been appointed and this was the first inspection she had been involved in. In addition, the Operations Manager, Mrs Woolnough, was present and provided additional information. The Service Providers, Mr & Mrs Sharples, attended for the feedback at the end of the inspection. Nine residents returned completed comment cards and 7 were received from relatives. Comments made have been included within the report where it is appropriate. Lunch was eaten with 2 residents and the opportunity taken to have a discussion about life at the home. The care records for 3 residents were looked at in detail and 2 of the residents were spoken to. Two staff files were also seen. There was also a brief tour of the building. Inspection findings showed that the care provided at this home is very good. What the service does well: What has improved since the last inspection? As stated above, the environment is maintained to a high standard and refurbishment is continuing. There have been improvements in some residents bedrooms, where en-suite shower facilities have been installed, and also in areas such as corridors, where new carpets have been laid and pictures put up. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 6 There have also been improvements to the external environment. Scaffolding, present at the last inspection, has now gone with the refurbishment of the windows and parts of the roof complete. A hard pathway now leads from the front of the home to the rear where there is a water feature and fountain for residents to enjoy. 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.V256334.R01.S.doc Version 5.0 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.V256334.R01.S.doc Version 5.0 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): 1, 3 & 6 The Service User Guide and Statement of Purpose provide sufficient information to ensure residents are able to make an informed choice to enter the home. No evidence was available to show that pre-admission assessments are taking place in all cases. This home does not provide intermediate care. EVIDENCE: No changes have been made to the Service User Guide and Statement of Purpose. Mr & Mrs Sharples stated that it is under review to reflect changes at the home. The current documents are contained within an information pack that is well presented and accessible to residents and those acting on their behalf. No pre-admission assessments were available on the resident files seen as part of this inspection. The records for this process could not be found and 2 residents spoken to could not recall a pre-admission assessment taking place, Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 9 although 1 did refer to answering questions when she visited the home to see her room prior moving in. There was no evidence of discussion with other professionals, i.e. social worker or GP. No admission to the home should take place unless a pre-admission assessment is undertaken and fully recorded. Pre-admission assessments should be kept on the resident file and form the basis of the initial care plan. See requirements. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 10 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, 8 & 10 Care plans are in place but the contents need to be improved and developed to provide better guidance for staff. Residents’ healthcare needs are met. Residents feel they are treated with respect and that their privacy and dignity is maintained. EVIDENCE: Three care plans were looked at in detail and it was disappointing to note that the progress seen at the last inspection has not been consolidated or maintained. Several issues were noted and were discussed with Mrs Fullerton and Mrs Woolnough. Care plans were not explicit. For example, one care plan stated that the resident’s personal care was “good” but did not state what, if any, assistance was needed from the staff. This also applied to the residents mobility, which was described as “good” but later in the care plan a risk analysis states that staff should “observe and encourage”. Only 1 of the care plans had been signed by the resident to show they had participated in the process and were in accordance with the plan of care. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 11 The daily records need to have more information. One entry read “good positive frame of mind” but did not give reasons as to why this was the case. The entry formed the impression that this was out of character. However, reference was later made to the resident being “paranoid” but there was no information about how the paranoia manifests itself or how staff should manage it. Risk reduction plans have not been completed. One care plan stated that the resident was at “high risk” of falling but there was no information about how the risk should be reduced. Another care plan listed several areas where the resident was “at high risk” but no risk reduction was recorded. These included becoming lost, leaving water running, financial abuse, burning themselves and self-harm. All are very significant risks. See requirements. Records of healthcare interventions were seen and these appeared timely and appropriate. The Head of Care described and very good relationship with the local GP surgery and visiting Community Nurses. The residents spoken to felt their privacy and dignity were well respected by staff. This was confirmed by the comments made in those comment cards returned by residents. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 12 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): 12, 13, 14 & 15 Residents stated that life at the home generally met their expectations and their preferences were respected. Residents confirmed that they are able to maintain contact with relatives and friends as they wish. Residents felt they could exercise choice over their daily living. Generally, residents enjoy the food and receive a nutritious and varied diet that caters for their needs and preferences. EVIDENCE: Two residents described their experiences at the home and they felt that the home mainly met their expectations. All returned comment cards stated that the home met their needs and expectations and that they felt well treated and cared for by staff. Some residents felt that activities did not always reflect their interests and spoke of preferring discussions groups, visiting speakers and videos. Positive comments were made about the art classes recently introduced to the home by Mrs Fullerton. All other residents expressed satisfaction with the activities at the home. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 13 Residents spoken to confirmed they are able to maintain contact with relatives and friends as they wish. All returned relative comment cards confirmed this. Residents felt able to make choices about how and where they spend their day and with whom. Residents stated that staff respect their choices. A meal was eaten with residents as part of the inspection process. Residents had chosen what they wished to eat but could not remember what they had specified. A copy of the day’s menu would have assisted residents. The food was freshly prepared and well presented. The cook confirmed that fresh provisions were delivered to the home on a regular basis. Residents stated that they had requested linen napkins to replace the paper ones provided by the home but nothing had been done to date. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 14 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): 16 & 18 Residents, relatives and visitors to the home generally know the complaints procedure. Most practice at the home protects residents from abuse. However, the practice of starting of new staff before CRB checks are complete is not in accordance with Regulations or safe practice. EVIDENCE: The home’s complaints procedure is displayed and well known to residents and relatives. No complaints have been received at the home since Mrs Fullerton commenced as manager. No complaints have been received about this service by CSCI in the last 12-months. Staff receive abuse awareness training and are conversant with the issues around adult abuse. Discussion with Mrs Fullerton revealed that new staff are working unsupervised prior to a full CRB disclosure being received. This is regarded as unsafe practice and is not in accordance with Regulations and the home’s procedural guidance. See requirements. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 15 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, 20, 21 & 26 The home is safe and well maintained. Residents have access to internal and external communal areas that are safe and comfortable. There are ample toilets and bathing facilities but communal bathing areas need to be de-cluttered. The home is clean and tidy with no unpleasant odours detected. EVIDENCE: Substantial work has been completed to the Old Hall, which now provides a very high standard of private and communal accommodation for residents. Work was continuing on the large function room at the end of the corridor at the time of inspection and the planned uses for this room were discussed. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 16 New paths have been laid that lead around the side of the home to a water and fountain feature. Internally, residents have easy access to communal space that is well decorated and furnished. Mrs Fullerton showed samples of the new chairs to be provided in the Dibben Wing of the home. Communal toilets and bathing facilities were seen as part of this inspection. Generally, all areas were clean and tidy. However, the bathroom on the 1st floor of the Dibben Wing was cluttered and uninviting. This bathroom had substantial quantities of items stored including dining chairs, wheelchairs, supplies of continence wear, a hoist, sit-on scales and walking frames. The hairdresser makes use of the sluice room, accessed via the above bathroom. The sluice itself required cleaning as it was affected by lime scale and there was also a toilet aid stored on the sluice drainer. Neither is inviting for residents having their hair done. The home was very clean and tidy with no unpleasant odours detected. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 17 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, 28, 29 & 30 Staff are employed in sufficient numbers to ensure the needs of residents are met. Current practice with regard to new staff does not ensure residents are always in safe hands (see also standard 18). The home has good recruitment policies that are in line with recognized best practice. Staff are well trained and competent. EVIDENCE: A copy of the staff rota for the week of inspection was provided and showed that, excluding the manager, a minimum of 4 care staff are employed between 07:30 and 18:00, with a minimum of 3 care staff on duty until 22:00. Information provided by Mrs Fullerton showed that 5 staff had left since June 2005 and that efforts were being made to fill all vacancies. Most vacancies are on night shifts and agency staff are currently filling these where necessary. Mrs Fullerton described current practice regarding recently recruited staff. This revealed that care staff are working unsupervised before a full disclosure has been received from the CRB. Application for Protection of Vulnerable Adults register entries is completed but this does not allow for appropriate safeguarding as the register will only show if a member of staff has been entered on the register. A requirement has been made. Please see standard 18. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 18 The home has good recruitment policies in place that include the completion of an application form, 2 written references and formal recorded interview. ManorCourt Care (Norfolk) Ltd is committed to effective staff training and this has generated commendation at previous inspections. The commitment of the organisation remains, however it was found that, following perusal of 2 new staff files, they have not received fully recorded induction training in line with the organisations policies. Mrs Fullerton advised that she had run out of the booklets used to record the induction training. As a consequence, there is no record of what training has been completed and this needs to be rectified without delay. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 19 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, 35, 36, 37 & 38 The current manager is registered with CSCI. The home uses good practices in regard to maintaining residents personal finances. Staff receive formal and informal supervision that is recorded. Generally, records are well maintained. The written policies and procedures safeguard residents although there were some examples where these were not fully complied with. The health, safety and welfare of residents, staff and visitors to the home is protected. EVIDENCE: Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 20 There are currently changes in the manager of the home. Mrs Fullerton commenced as manager in June 2005, but was due to leave the home the day after this inspection. A new manager has been appointed and is now in post. Mrs Fullerton had completed the registration process and the newly appointed manager is currently registered at another home. The Head of Care has responsibility for maintaining residents personal allowances where necessary. Good practice was seen and records were robust. A spot check of monies held for each resident was undertaken and this showed that all records complied with monies held. Audits are carried out regularly to ensure entries are correct. Arrangements are in place to ensure residents can access their money at weekends. Mrs Fullerton described the supervision processes in place. All supervision is recorded and takes the form of both formal and informal supervision. Initial supervision was in the form of “getting to know you” sessions, with more formal supervision taking place after this. The process was delegated to the Head of Care and senior carers, with Mrs Fullerton keeping an overview of the process. Unless otherwise stated within this report, good records were seen. There was evidence that the home’s policies and procedures were not always complied with and these have been specified throughout the report. In addition, it was established that the home has not been advising the CSCI of significant events that affect the resident’s health, safety or well-being. Two examples of this were noted and Mrs Fullerton was requested to ensure the formal notifications were forwarded without delay. See requirements. Some records regarding the health and safety of residents, staff and visitors to the home were seen and found to be in good order and up to date. Accident records were well written but would benefit from a regular audit to ensure that any patterns of accidents or incidents are picked up and dealt with in a timely way. The home complies with requirements made by other authorities and Mr Sharples described the action taken following a recent Environmental Health Inspection. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 21 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 2 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 2 3 Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 22 No 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 OP3 Regulation 14 Requirement The registered person must ensure that no resident is admitted to the home until a full needs assessment has been carried out and shows the home can meet the residents’ needs. 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. The registered person must ensure that no new staff work unsupervised pending a full CRB disclosure The registered person must ensure that the CSCI is advised of all notifiable occurrences without delay in compliance with this Regulation. Timescale for action 21/11/05 2 OP7 15 21/11/05 3 OP18 19 24/10/05 4 OP37 37 24/10/05 Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 23 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 2 3 Refer to Standard OP15 OP21 OP30 Good Practice Recommendations It is recommended that a copy of the day’s menu is made available to residents to help them remember what they have chosen to eat. It is recommended that the bathroom on the 1st floor Dibben Wing is tidied and not used for the storage of equipment and aids. It is recommended that the induction training completed by new staff is fully recorded using the organisations training booklets. Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Bilney Hall DS0000045248.V256334.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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