CQC report explained · a residential care home
What the CQC found at Bilney Hall
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Bilney Hall was inspected but not rated; inspectors found mostly suitable infection control, but chipped kitchenette worktops needed refurbishment.
This was an announced, targeted inspection on 20 January 2022. The inspection focused on infection prevention and control during COVID-19, and on whether staffing pressures were affecting care.
Inspectors found good practice in the use of PPE, ventilation, social distancing guidance and COVID-19 care plans. They were assured about visiting arrangements, testing, safe admissions and managing infection outbreaks.
There was one concern. Some kitchenette worktops were chipped and no longer had an intact surface, creating an infection control risk. The home was inspected but not rated, so this report does not give a full quality rating.
PPE use
Staff were observed using PPE in line with government guidance to help protect people, visitors and staff.
“Staff were observed to be wearing Personal Protective Equipment (PPE) in line with current government guidelines, to ensure the safety of people supported, visitors and the staff team.” from the report
COVID-19 care plans
People had clear COVID-19 care plans intended to reduce risks and support them in a personalised way.
“People had clear care plans in place in relation to COVID-19, this ensured risks could be mitigated and people could be supported in a personalised way.” from the report
Visits
People continued to receive visits in line with government guidance, and a visiting pod was available.
“People continued to receive visits from their loved ones in line with current government guidance. A visiting pod had also been created to further support with visits.” from the report
Chipped worktops
needs fixingSome kitchenette worktops were chipped and no longer had an intact surface. Inspectors said this created an infection control risk and that refurbishment was needed.
“Areas of the service required refurbishment. These included kitchenette areas where the worktops had become chipped and were no longer an intact surface. This presented a risk of infection control.” from the report
- 01Have all the chipped kitchenette worktops been repaired or replaced, and when was this completed?
- 02How did COVID-19-related staffing pressures affect people using the home at the time of the inspection?
- 03How are PPE use, staff testing and infection control checks monitored now?
- 04Are visits still taking place in the same way, including use of the visiting pod?
- 05How are COVID-19 risks recorded and reviewed in each person's care plan?
This was a targeted inspection of infection prevention and control and staffing pressures; it did not assess the other four CQC questions and the service was not rated. This explanation was written from the published report of 24 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2019
Rated Good overall; inspectors found kind, effective care, but safety systems and staffing at busy times needed improvement.
This was an unannounced inspection on 18 September 2019. Inspectors spoke with people, relatives and staff, observed care and mealtimes, checked medicines, and reviewed care plans, staff files and other records.
The home supported 62 older people, mainly people living with dementia. Inspectors found caring staff, good healthcare support, safe medicines practice, suitable activities and improved staffing. People were generally treated with dignity and respect.
The overall rating was Good. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, having fallen from Good at the previous inspection. Inspectors found faulty equipment, gaps in risk records and concerns about staff availability at busy times.
Improved staffing
Staffing had improved, agency staff had not been used for more than five months, and regular staff provided more consistent support.
“Staffing levels had improved and people received consistent support from regular staff.” from the report
Kind and respectful care
Inspectors saw positive relationships between staff and people. Staff understood dementia and supported people's choices, routines and independence.
“Staff were observed to be caring and had good interpersonal skills and had a good understanding of dementia and how it might impact on the person.” from the report
Safe medicines practice
Medicines were administered safely. Staff training, competency checks and audits were in place.
“Staff administered medicines to people safely and there were robust audits in place to check that this was the case.” from the report
Good health and food support
People were supported to eat and drink enough, with choices suited to their needs. Healthcare needs were monitored and acted on.
“People were supported to eat and drink in sufficient quantities and in line with their individual needs.” from the report
Building safety checks
seriousSeveral environmental risks were found during the inspection. The home fixed them straight away and said it had strengthened its checks, but inspectors still recommended daily building walkarounds.
“Despite this we found several faulty restrictors, A radiator cover which had become dislodged and a sensor alarm which could be a trip hazard for people in close proximity.” from the report
Staff availability at busy times
needs fixingSome people, relatives and staff said it could be difficult to find help, particularly in the mornings, after lunch and at weekends. Inspectors recommended reviewing staffing levels for these periods.
“We recommend the provider reviews staffing levels and considers if they are sufficient to cover busy times of the day.” from the report
Incomplete risk information
needs fixingSome care records contained contradictory information or did not link important risks together. This could make it harder for staff to provide consistent support.
“We found the standard of records keeping needed to improve to ensure risks to people were clearly documented and helped to ensure staff could consistently meet people's needs.” from the report
Care plans not personal enough
needs fixingSome care plans did not explain people's preferred routines, the reasons for anxiety or how staff should reduce distress. The home had started reviewing them after the inspection.
“We found however some of the information in the care plan was generic and did not clearly reflect people's preferences.” from the report
- 01What changes have been made to check window restrictors, radiator covers and sensor alarms, and how are these checks now recorded?
- 02How do you make sure there are enough staff during mornings, after lunch and at weekends?
- 03Have all care plans been updated with each person's routines, preferred music and ways to reduce anxiety or distress?
- 04How are care staff expected to support people to take part in activities and daily living when activity staff are busy?
- 05How do your audits now measure people's experiences, especially those living with dementia?
This was an unannounced inspection of the care, premises and management of the home, covering all five CQC questions; all areas were assessed during this visit. This explanation was written from the published report of 31 December 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bilney Hall
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- December 2019Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementstayed Requires improvementWell-led: Inspected but not rated
- August 2016Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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