Care Home: Bilney Hall

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What the care home does well Prospective residents have their needs assessed prior to admission and the information is used as part of the care planning process. Each person at Bilney Hall has a detailed care plan which describes their health, personal and social care needs. Residents have access to healthcare professionals and they are protected by the home`s medication policies and procedures. Residents have the opportunity to take part in a number of activities, hobbies and pastimes and are supported to maintain contact with family, and friends, according to their wishes. Residents, their families and friends know their complaints will be listened to, taken seriously and acted upon. Robust procedures are in place that help protect residents from abuse. Bilney Hall continues to provide a clean, safe and well maintained environment for residents, with ongoing improvements being made to various internal and external areas. Bilney Hall has robust recruitment policies and practices, the staff have a good mix of skills and they are trained and competent. Residents live in a home, which is run in their best interests by a competent manager/owner. The health and welfare of residents and staff are promoted and protected by the home`s policies and procedures. What has improved since the last inspection? Recruitment practices were seen to be more robust with appropriate references having been received for new members of staff. What the care home could do better: Bilney Hall continues to meet and, in many cases, exceed the outcome areas inspected and no requirements or recommendations have been made as a result of this inspection. Key inspection report Care homes for older people Name: Address: Bilney Hall East Bilney Dereham Norfolk NR20 4AL     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Debby Ames     Date: 0 9 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 33 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 33 Information about the care home Name of care home: Address: Bilney Hall East Bilney Dereham Norfolk NR20 4AL 01362860246 01362861122 bilneyhall@manorcourtcare.co.uk www.manorcourtcare.co.uk Manorcourt Care (Norfolk) Ltd care home 54 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 54 The registered person may provide the following category of service only: Care Home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category (Code OP), Dementia (Code DE). Date of last inspection Brief description of the care home Bilney Hall is a care home providing personal care and accommodation for up to 31 older people, 19 of whom may have 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 Care Homes for Older People Page 4 of 33 54 0 Over 65 0 54 Brief description of the care home 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. Twentyone 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 basic weekly fee is currently £650 plus top-ups for one-to-one support as necessary. Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our 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 providers, the residents and their relatives, as well as others 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 the current judgements for each outcome group. The fieldwork of this inspection was carried out over a period of five hours and included a tour of the premises, inspection of staff and residents records and the homes records relating to health and safety. Discussions also took place with the manager and a number of residents. Six questionnaires were completed or returned to the Commission by residents, which contained mostly very positive comments and responses. Four questionnaires were Care Homes for Older People Page 6 of 33 returned by staff members, three of which contained mostly negative responses and no additional comments, one had mostly very positive responses with additional comments saying: ...we give excellent care... and ...could do with more staff... Some of the additional comments made by the residents who returned questionnaires included: ...they do their best to make you feel happy and always listen to you if you have a problem... ...the meals get a bit repetitive... ...there are not enough outings for us residents but understand that is due to a shortage of carers to go with you... ...no doubt there is a shortage of funds to cover any entertainment or outings... ...there is a committee of people called Friends of Bilney Hall, whom I think could help more, e.g. accompany the residents on their outings and maybe take them for afternoon tea or morning coffee somewhere... ...have the freedom to go outside for some fresh air or sit in the sun with a cup of tea and read the newspaper... ...the home doesnt show enough interest in Holy Communion... Meanwhile, the manager of Bilney Hall completed and returned a clear and detailed Annual Quality Assurance Assessment (AQAA) to the Commission, as requested, prior to this inspection. Care Homes for Older People Page 7 of 33 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Care Homes for Older People Page 8 of 33 order line 0870 240 7535. Care Homes for Older People Page 9 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents have their needs assessed prior to admission and the information is used as part of the care planning process, which helps to ensure peoples needs are met. Evidence: Three care plans were looked at and a discussion was held with the manager, which confirmed that comprehensive pre-admission assessments are carried out for prospective residents to establish whether Bilney Hall is able to meet the persons needs and help them to make an informed choice about moving into the Home. Initially, a Customer Enquiry Form is completed, which contains general personal details and visit information, which comprises details of the staff member undertaking the visit, providing a brochure and explanations in respect of the Organisations philosophy, finances, trial visit, funding and the next steps - i.e. the pre-admission assessment, if the person wishes to proceed. Care Homes for Older People Page 11 of 33 Evidence: It was confirmed that prospective residents and their relatives are very actively involved in the pre-admission assessment process and all the information gathered is used to form the basis of the persons care plan. Meanwhile, of the six residents questionnaires that were completed, five responded yes to the question: Did you receive enough information to help you decide if this home was the right place for you before you moved in? One person responded no stating that their family had made the decision for them. Care Homes for Older People Page 12 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person at Bilney Hall has a detailed care plan which describes their health, personal and social care needs. Residents also have access to healthcare professionals and they are protected by the homes medication policies and procedures. All of these factors help ensure that residents health care needs are fully met. Evidence: Three care plans were looked at in detail and each one was seen to contain a very good level of detail covering peoples individual health and personal care needs, with good evidence of consistency in care provision for each person. The front part of the care plans contained the persons name (including their preferred name), date of arrival, date of birth, room number, family doctor registration and details of previous doctor. Meanwhile some of the other sections within the care plans were seen as follows:1. On Admission Care Homes for Older People Page 13 of 33 Evidence: (a) Personal Details - which included a copy of the completed care assessment, next of kin, previous residence, current medication and past medical history. (b) Clinical Observations on Admission - this section showed information relating to weight, temperature, pulse, blood pressure and details of any healthcare professionals currently involved. (c) Life History, Family Life, Hobbies & Interests - all three files seen contained detailed information and gave a good insight to the person and their lifestyle prior to moving into the Home. (d) End of Life Care - this section was seen to contain information regarding peoples wishes - i.e. burial or cremation etc, next of kin to contact and any special requests. A Consent to be Photographed form was also seen in each of the files. 2. Risk Profile This area was noted to be extremely well completed with very comprehensive but easy to follow information and records that were well maintained and up to date such as:* Dependency Assessment * Dependency Assessment Score Summary Information for Reviews - these were seen to have been regularly reviewed and updated as necessary. * Drugs and Discharge Summary from Hospital (where applicable) * Waterlow Pressure Ulcer Risk Assessment - these were seen to have been regularly reviewed and updated as necessary. * Mental Capacity Assessment - which contained information such as; family look after finances and impairment prevents [name] from administering their own medication. * Risk Assessment for Self-Administration of Medication * Assessment of Risk of Falls and Preventative Measures Care Homes for Older People Page 14 of 33 Evidence: * Moving and Handling Risk Assessments * Personal Risk Assessments * Pain Assessment Record * Nutritional Risk Assessment * Regular Clinical Observations Record 3. Care Plan This section was separated into sub-sections and, again, found to be extremely well detailed providing good information in respect of how people wanted to lead their lives, with choices and decision making being genuinely encouraged and promoted. Some of the information and comments noted included the following: ...likes to get up between 8am and 9am... ...needs some help washing and dressing and is quite happy for staff to help... ...likes to have breakfast in own room... ...prefers a female carer but a male carer is acceptable... ...likes to have a bath at least once a week with regular showers in between... ...likes to wear lipstick and perfume - prefers wearing trousers... ...quite able to make choices but just needs a little time to think things over... ...chats with staff help to make [name] feel safe and a short walk round the garden will help with anxiety... Regular evaluations and updates were noted throughout the care plans. 4. Daily Notes - All of these were seen to be clear, informative and respectfully written Care Homes for Older People Page 15 of 33 Evidence: The lunchtime medication round was observed being carried out by a trained member of staff whose practice was seen to be professional and caring. Bilney Hall uses a monitored dosage system, with separate coloured blister packs for different times of the day. A separate cupboard was seen for the storage of homely remedies, insulin needles, urine strips and sample bottles and a homely remedies book was seen for items such as paracetamol and senna etc. A further cupboard was seen to store dressings and creams etc. A secure locked cupboard was seen for storing controlled drugs and the controlled drugs record book was seen to contain two signatures as required. No errors or omissions were noted from the records seen during this inspection It was confirmed by the manager that people are supported to self-medicate where possible and appropriate risk assessments are put in place to support this where relevant. Observations and discussions with some of the residents confirmed that the people living at Bilney Hall are treated with respect and genuinely valued as people. Meanwhile, all six residents questionnaires contained the response always to the question: Do you receive the care and support you need? And five out of six people responded always to the question: Are the staff available when you need them? One person responded usually. One resident commented: ...they do their best to make you feel happy and always listen to you if you have a problem... Care Homes for Older People Page 16 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have the opportunity to take part in a number of activities, hobbies and pastimes and are supported to maintain contact with family, and friends, according to their wishes. Evidence: Bilney Hall was seen to have a good selection of organised activities available on a regular basis, plus seasonal events, such as: * Clothes Lady * Cookery 1:1 sessions in 1950s designed kitchen * Body Shop & Christmas Fayre * Board Games * Reminiscence * Banjo Man Care Homes for Older People Page 17 of 33 Evidence: * Keyboard Music * Beetley School Choir * Clearer Productions * Minibus Shopping Trips * Entertainer * Christmas Lunch at the Pub * Bingo * Memory Joggers * Crafts * Table Arrangements * Story Telling * WII (Interactive Game) * 1:1 Sessions * Christmas Party From the records seen it was evident that people are supported to engage in activities of their choice and some entries in the daily notes looked at were as follows: ...enjoyed the banjo man... ...helped decorate the tree... ...enjoyed the entertainment and sing-along... ...had visit from [relative]... Care Homes for Older People Page 18 of 33 Evidence: ...went to day centre... ...spent time knitting and watching television... ...enjoyed having hair done... ...spent time reading the newspaper... It was noted from the Healthcare Homes Annual Quality Assurance Report however that of the fourteen residents questionnaires that were returned, six people responded yes that they enjoy the activities on offer, five responded no and three gave no answer. From the six residents questionnaires returned to CQC, some of the additional comments included: ...there are not enough outings for us residents but understand that is due to a shortage of carers to go with you... ...no doubt there is a shortage of funds to cover any entertainment or outings... ...there is a committee of people called Friends of Bilney Hall, whom I think could help more, e.g. accompany the residents on their outings and maybe take them for afternoon tea or morning coffee somewhere... ...have the freedom to go outside for some fresh air or sit in the sun with a cup of tea and read the newspaper... ...the home doesnt show enough interest in Holy Communion... A discussion with the manager confirmed that Holy Communion used to take place monthly but there is a problem securing regular visits from the local vicars at present, although this is being looked into. One resident does receive visits from their own vicar and other residents are able to join in if they wish. It was also acknowledged that one-to-one staff to resident ratios are difficult for large numbers but the activities person is currently researching interim ideas such as sightseeing in the mini bus. Communication books were noted to be maintained in each persons room, which are Care Homes for Older People Page 19 of 33 Evidence: usually completed and updated by staff and relatives. These were seen to be an effective way of letting relatives know what activities the resident has taken part in and also, on occasions, relatives might leave a note to say: ...[name] was asleep throughout visit - please tell them I called... It was evident that visitors are always made welcome and a number of people were observed visiting throughout this inspection. In respect of meals and mealtimes, Bilney Hall has a four week seasonal menu, with a choice of main meal and desserts. The manager confirmed that further alternative options are always available upon request. Some examples from the Spring Menu - Week 1 - included: Monday (a) Finest Pork Sausages Served with Caramelised Onion Gravy and Creamed Potatoes. (b) Mince Cobbler Savoy Cabbage and Carrots (a) Lemon Sponge Pudding with Lemon Sauce (b) Fresh Fruit Salad (c) Yoghurt Thursday (a) Traditional Beef Stew with Herb Dumplings (b) Thai Butternut Squash and Vegetable Curry with Rice Cauliflower and Broccoli Mix (a) Strawberry Cream Tart (b) Fresh Fruit Salad Care Homes for Older People Page 20 of 33 Evidence: (c) Yoghurt From the Healthcare Homes Annual Quality Assurance Report, twelve out of fourteen people responded yes in the questionnaire that they enjoy the choice of food and drinks and two responded no. From the six residents questionnaires returned to CQC, three people responded always that they like the meals, one responded usually and two people responded sometimes. One of the additional comments said that the meals get a bit repetitive. Care Homes for Older People Page 21 of 33 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents, their families and friends know their complaints will be listened to, taken seriously and acted upon. Robust procedures are in place that help protect residents from abuse. Evidence: Of the six questionnaires that were returned to the Commission prior to this inspection, four responded yes that they know how to make a complaint and two people responded no. Five out of six people responded yes that they know who to speak to if they are unhappy. Meanwhile, from the Healthcare Homes Annual Quality Assurance Report, ten people responded yes in the questionnaire that they know who to raise a concern with, three responded no and one person gave no answer. All thirteen relatives who responded to the questionnaires for the Healthcare Homes Annual Quality Assurance Report responded yes that they know who to raise a concern with. A discussion with the manager confirmed that one formal complaint has been received since the last inspection and this was dealt with promptly in accordance with the Homes complaints procedure. Care Homes for Older People Page 22 of 33 Evidence: It was also confirmed that a copy of the complaints procedure has been given to each resident and is available in their rooms. From information seen in the recent Healthcare Homes Annual Quality Assurance Report, the manager plans to develop an email contact list with relatives and representatives, which will help further improve communications. Meanwhile, Bilney Hall has policies and procedures in place in respect of adult protection, prevention of abuse and whistle blowing and staff records confirmed that staff are well trained in these areas. Care Homes for Older People Page 23 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home continues to provide a homely, clean, safe and well maintained environment for residents, with ongoing improvements being made to various internal and external areas. Evidence: A tour of the premises showed Bilney Hall to be a very clean, hygienic and well maintained environment, with a very homely atmosphere. All the responses to the Healthcare Homes and CQCs Questionnaires were very positive in respect of the cleanliness, comfort and homeliness of Bilney Hall. One of the communal areas was seen to be a very well designed 1950s style kitchen, which is used by the residents for cookery and has a number of 1950s style features, equipment and utensils. A new, larger laundry room was also seen to have been completed to a very high standard Meanwhile, it was confirmed in the AQAA that the following improvements have also taken place since during the last twelve months: One of the residents lounges has been divided into two rooms and furnished to a high standard, the conference room Care Homes for Older People Page 24 of 33 Evidence: has been converted into a new residents lounge, a bathroom has been installed on the ground floor of the Old Hall, more profiling beds have been purchased and all rooms are refurbished when they become vacant. Further plans for improvement were noted as: The completion of the new twenty-one bed extension, for low dependency EMI residents, demolish dilapidated outbuildings to give a better outlook and create an administrators office. Care Homes for Older People Page 25 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Bilney Hall has robust recruitment policies and practices, the staff have a good mix of skills and they are trained and competent. Evidence: Two staff files were looked at in detail during this inspection and both were seen to contain all the relevant records such as job application form, interview record checklist, contract, job description, photograph, proof of identification, references and clear, enhanced, disclosure from the Criminal Records Bureau (CRB), all of which helped to confirm that Bilney Hall continues to have robust recruitment procedures. Other information seen in the staff files included a record of induction and evidence of training in areas such as: * Role of the care worker * Moving & Handling * Care Planning * First Aid Care Homes for Older People Page 26 of 33 Evidence: * Infection Prevention and Control * Safe Food Handling * Health & Safety * Practical Skills * Medication * Developing as a Worker * Communication Skills * Safeguarding Vulnerable Adults * Mental Capacity Act * Stress Awareness * Risk Assessments * Loss & Bereavement * Dementia * Pressure and Ulcer Prevention * Fire Awareness and Prevention The rotas were also looked at during this inspection and the numbers reflected a good level of staff on duty at all times and observations during the inspection also confirmed sufficient numbers of staff on duty to meet peoples needs as required. Staff meetings were confirmed to be held on a monthly basis, during which staff are informed of what is happening in the Home and any issues raised by staff can be discussed and acted upon. Meanwhile, four staff questionnaires were returned to CQC and three out of the four contained negative responses throughout and no additional comments. One person Care Homes for Older People Page 27 of 33 Evidence: responded with mostly very positive responses and additional comments that said: ...we give excellent care... and ...could do with more staff.... Eleven members of staff returned questionnaires for the Healthcare Homes Annual Quality Assurance Report and, of these, ten responded yes that they had undertaken training or development, one responded no. All eleven confirmed they had received a job description. Care Homes for Older People Page 28 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home, which is run in their best interests by a competent manager. Residents are safeguarded and the health and welfare of residents and staff are promoted and protected by the homes policies and procedures. Evidence: The manager of Bilney Hall has been in post since 2005 and is a qualified nurse, with an HNC in business and finance. A very good internal Quality Assurance system continues to be carried out on an annual basis and residents meetings are held on a regular basis, in order to ensure Bilney Hall continues to be run in the best interests of the people living there and that peoples views are listened to and taken into account. It was acknowledged in the Healthcare Homes Annual Quality Assurance Report that resident attendance at formal meetings is quite low at 31 and the action plan confirmed that consideration should be given to introducing alternative formats for Care Homes for Older People Page 29 of 33 Evidence: gathering residents opinions... It was stated in the AQAA that improvements during the last twelve months have included the senior team participating in the supervision and induction process and that Bilney Hall has gained the Investors in People status for the second time. Also, from the information provided in the AQAA, Bilney Hall has good quality policies and procedures, all of which were noted to have been regularly reviewed at various intervals. Records showed that regular audits take place in respect of any monies held on behalf of residents and evidence of safekeeping valuables and personal possessions was also noted. Meanwhile, the health and safety records seen during the inspection were found to be satisfactory and servicing certificates were seen for areas such as the lift, hoists and electrics. Evidence of fire safety checks, inspections and a fire risk assessment were also seen Cleaning materials and hazardous chemicals were seen to be stored appropriately and no obvious safety hazards were noted at the time of the inspection. Very good records of falls are maintained and regularly audited and accidents are also recorded appropriately. Notifiable incidents continue to be reported in detail to the Commission, together with information in respect of action taken. Care Homes for Older People Page 30 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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