Inspection on 26/02/07 for Bilney Hall

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 10/02/06

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 Maggie Prettyman Unannounced Inspection 26th February 2007 09:45 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.V331921.R02.S.doc Version 5.2 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.V331921.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bilney Hall Address Bilney Hall East Bilney Dereham Norfolk NR20 4AL 01362 860246 01362 861122 bilneyhall@manorcourtcare.co.uk www.manorcourtcare.co.uk Manorcourt Care (Norfolk) Ltd 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) Mrs Elizabeth Carlton 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.V331921.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 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. The current range of weekly fees is £500 - £600 Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. What the service does well: What has improved since the last inspection? Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 6 The new manager and her team have made many changes and improvements in the home since the last inspection. Some of the improvements made include; • • • • • • • • • • • • The manager has been registered with the commission The needs assessment procedure has been expanded Service user life histories are being gathered Plans of care are now detailed and reviewed Personal care tasks are being audited The nutritional screening system is being updated A new policy and procedure for medicine administration is in place Communication books record significant events in service user daily lives A chef has been appointed and menus have been diversified with greater choice provided A system of staff supervision has been implemented A full programme of renovation and refurbishment has taken place New training facilities have been provided 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. The summary of this inspection report can be made available in other formats on request. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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.V331921.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 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 with the home. No service user moves into the home without having their needs assessed. The home does not currently normally offer respite care services. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user guide and terms and conditions of residence provide good information about the home and its services. During the inspection Service User Guides were seen in all service user rooms. Inspection of service user files demonstrated that signed contracts are in place for all service users. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 9 Evidence of good needs assessments being conducted prior to service user admission was found in all files inspected. The format for this assessment has been updated and improved by the new manager to include mental health needs and lifestyle risk assessments. The manager stated that respite care is not currently being offered by the home. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 Service users 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 are protected by the homes policy and procedures for administering medication. Service users feel that they are treated with respect and their right to privacy is upheld. End of life care is provided carefully and sensitively. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Detailed and reviewed plans of care were found in place for all service users. Records are detailed and professionally kept. Service user files demonstrated that life histories are being put in place for as many service users as possible. The home is trying out new ways of auditing daily personal care tasks. During Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 11 the inspection it was noted that considerable duplication of records takes place. It is recommended that the home consider reducing duplication of some records. Examination of service user files demonstrated that great attention is being paid to make sure that the health care needs of service users are met. Evidence of work to promote continence among service users was seen. The manager has established baseline health assessments for all service users. Evidence that service users medication is being reviewed was seen. A file of current MDA alerts is kept in the office. A visiting GP was interviewed, and this together with pre inspection questionnaire feedback demonstrated that services provided by the home in this area are of a high standard. The manager has written and implemented a new medication policy and procedure. Part of a drugs round was observed and found to be conducted to a high standard. Records were inspected and found to be up to date audited and accurate. The manager has liaised with the local pharmacy to significantly improve the safety of the current dispensing system. A new system of dispensing will be implemented shortly to further improve the service provided. Evidence of regular training in medication procedures was seen. Many service users were interviewed during the inspection and all spoke highly of the way that the home respects their individuality and privacy. Staff are trained at induction in this respect. Post is given to service users unopened and the facility for private telephones was seen in service user rooms. Name of choice is displayed on individual rooms. Clothes are labelled and carefully sorted. The home plans to work towards implementing the Liverpool care pathway in conjunction with district nursing services to support end of life care. Evidence that service users are able to remain in the home if they choose to receive palliative care was seen. The family of service users are consulted and supported. Records demonstrated a caring and compassionate approach to the care of service users ending their lives. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Service users find that the lifestyle in the home matches their expectations and preferences. Service users maintain contact with their family friends and community. Service users are helped to exercise choice and control in their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence of a variety of social activities was seen during the inspection. The life story work being conducted with service users is supporting the provision of appropriate activities. A list of activities is in the hall for relative’s information. Communication books kept in service users rooms record activities and events participated in. The home has a Friends group, which organises fundraising events and activities. Details of village events were seen displayed in service user lounge Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 13 areas. Schools and community organisations visit the home. Communion services are given regularly. Feedback from pre inspection questionnaires as well as interviews conducted during the inspection demonstrated that visitors are welcomed and supported by the home and its staff. The new manager is working towards service users actively participating in residents meetings and being represented on the Friends committee. Prospective staff are introduced to service users. Evidence during the inspection of service users choosing their rising times, meals and where to eat and which lounge to sit in was seen. Service users rooms were found to have an array of personal belongings. The Access to records policy and procedure was found in all service user rooms. Information about advocacy is clearly displayed in the homes hallway. A professional and enthusiastic team of staff in the kitchen provide excellent food with a wide variety of choice and style. The kitchen was found to be spotless and well organised. A chef has been appointed to oversee the introduction of innovative and tasty meals. The home is in the process of updating its nutritional assessment system. The head cook ensures that specialised diets and nutritional needs are specifically catered for. Lists of service user likes and dislikes are clearly displayed in the kitchen. Service users said that they have been involved in the development of menus. A luncheon was observed with staff providing support discreetly and sensitively. Care has been taken to ensure that the new conference facility does not intrude on the service provided by the kitchen on a daily basis. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Service users complaints are listened to and acted upon. Service users are protected from abuse Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No formal complaints have been received by the home since the last inspection. Feedback from service users questionnaires and interviews with service users during the inspection demonstrated that action is taken to respond to minor complaints and comments. A copy of the complaints procedure was seen every service users room and is also displayed in the hallway. A file of compliments is kept. It is recommended that the home records and audits minor complaints, compliments and comments about the service to further inform its practice and the development of the home. Training records demonstrated that staff are trained in adult protection during induction, and this training is updated annually. A copy of the whistle blowing procedure was seen displayed in the staff room. The home has appropriately informed adult protection services on behalf of a service user. The home is in the process of reviewing its service provision in respect of service users with behaviour that challenges. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 24 and 26 Service users live in a safe well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service user bathing areas are comfortable and homely. Service user bedrooms are safe and comfortable and contain their personal possessions. The home is clean, pleasant and hygienic. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home and its grounds are accessible and well-maintained meeting individual and collective needs in a safe homely way. Records demonstrated an ongoing process of building development and maintenance, with work Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 16 conducted to a high standard. Action required after an EHO visit has been taken. CCTV monitoring is of entry and exits only and does not intrude on the privacy of service users. A new conference facility and training suite has been developed this year. Great care has been taken to ensure that its use does not affect the ongoing life of the home. Communal spaces in the home and its grounds were seen to be homely pleasant and comfortable, although some seating could be improved to better suit service user needs. The dining room is extremely comfortable and relaxing. The grounds consist of open parkland as well as a secure sensory garden. The overall environment is welcoming and relaxing with service user needs being well catered for. Sufficient and suitable lavatories and bathing facilities are provided. These facilities are clearly marked. All service user rooms have en suite facilities. Bathrooms were found to be uncluttered and tidy with pleasant décor and pictures, making them homely and welcoming. Service user individual rooms were found to be safe and comfortable, with a wide array of personal possessions and furniture. Doors are kept closed unless a service user wishes otherwise. A detailed tour of the premises demonstrated the home to be thoroughly clean, pleasant and hygienic. The laundry area is due to be upgraded, but was found to be tidy and well organised, with suitable clothes and linen washing facilities. Suitable hand washing facilities and antibacterial gel are provided throughout the home. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Service user needs are met by the numbers and skill mix of staff Service users are in safe hands at all times. The home must improve its standards for references gained for staff. Staff are trained and competent to do their jobs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A rota of staff provided demonstrated that staff numbers have improved since the last inspection, and that excessive hours are not now being worked. There has been a large turnover of staff in the past year, but steady recruitment has served to replace staff that have left. The home is committed to the training of staff to NVQ standards and an excellent programme of NVQ training is in place, resulting in high levels of achievement by the staff team. Inspection of staff files demonstrated that in general the requirements of the standards are met. However references were not always in place to the standard required. It is required that the home recruits staff in line fully with the care standards. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 18 Evidence of an excellent system of staff training including induction and ongoing updates was seen. Records are held for all staff, with a wide range of additional as well as mandatory training recorded. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36 and 38 Service users live in a home which is run and managed by a person fit to be in charge. Service users benefit from the ethos, leadership and management of the home. The home is run in the best interests of service users. Service users financial interests are safeguarded. Staff are appropriately supervised. The health, safety and welfare of service users and staff are promoted and protected. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 20 EVIDENCE: The homes manager has completed her registration with the commission since the last inspection. She is trained, knowledgeable and caring, displaying a good grasp of the issues and needs of a home of the type that she is running. The manager has implemented a wide variety of new systems and good practice since her appointment, meaning that the lives and lifestyles of service users have significantly improved. Increases in administrative demands as further auditing and development is achieved may mean that more administrative support may be needed. Service users benefit from the ethos, leadership and management approach. Service users commented that the home has a warm and positive atmosphere. Information from and consultation with service users informs and directs the development of the home. A service user survey has been undertaken using the same format as last year. Comments and suggestions are being compiled into a report to inform change in the home. An annual development plan is being written to reflect these results. Money held on behalf of service users was checked and found to be accurately recorded. The records demonstrated that regular audit takes place. Evidence of safekeeping of valuables and personal possessions was seen during the inspection. Evidence of regular staff supervision and team meetings was seen during the inspection. The manager has implemented a confidential supervision system, with performance issues recorded as file notes in staff files. Observational supervision is recorded in individual training and development plans for staff. The health, safety and welfare of service users and staff are promoted and protected. Mandatory training for all staff given during induction and is updated annually. Maintenance records are kept and water temperatures are regularly checked and recorded. The home is tidy and free of trip hazards. Records of falls are kept and are being audited. Accidents are recorded and reported. Notifiable incidents are reported to the commission with high standards of detail including action taken. Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X X 4 X 4 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 4 X 4 Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19 Requirement The home must ensure that adequate references are gained for staff prior to their appointment Timescale for action 31/03/07 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 Refer to Standard OP16 OP7 Good Practice Recommendations A record and audit of minor complaints and comments about the home should be kept. The home should consider reducing the duplication of records in the home Bilney Hall DS0000045248.V331921.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V331921.R02.S.doc Version 5.2 Page 24 - 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. 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