CQC report explained · a nursing home
What the CQC found at Bilton Hall Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2022
Bilton Hall Nursing Home rated Requires Improvement; inspectors found personalised care but gaps in staff training created safety risks.
This was an unannounced focused inspection on 3 May 2022. Inspectors looked at whether care was safe, responsive and well-led, after concerns about catheter care and food. They spoke with people, a relative and staff, and checked care, medicines, recruitment and management records.
The home was not always safe because many staff had not completed important training, including training about diabetes and falls. Some staff also lacked the knowledge needed for catheter care. Medicines were generally managed safely, but records showing where creams should be applied were not always complete.
Responsive care was rated Good. Care plans reflected people's needs and choices, information was available in different formats, and activities were provided. Safe and well-led were rated Requires Improvement, as they were at the previous inspection. The home was no longer in breach of some regulations identified previously, but it remained in breach of the staffing regulation.
Personalised care
Care plans reflected people's needs and preferences. Staff were described as understanding people's choices and communication styles.
“Care plans were person centred and clearly reflected peoples support needs in line with their preferences.” from the report
Activities and communication
People could take part in a wide range of activities. Information was provided in different formats to help people take part in decisions and activities.
“There were a wide variety of activities available for people to participate in.” from the report
Medicines mostly managed safely
Inspectors found that people received the right medicines at the right time, with regular reviews and safe storage and recording systems.
“People received the correct medicines at the right time.” from the report
Improvement work had started
The new general manager had a plan to improve care, staff training, the premises and the service's culture.
“The general manager has developed a plan to review care practices and intends to improve the standard of care provided to people.” from the report
Staff training and catheter care
seriousMany staff had not completed essential training, including diabetes and falls prevention. Not all staff had enough knowledge to provide safe catheter care, placing people at risk of harm.
“Staff did not have the correct training or knowledge to provide safe care.” from the report
Topical medicine records
minorBody maps were not always available to show staff where to apply creams and other topical medicines. The CQC recommended that the provider update its recording practice.
“People who received topical medicines did not always have body maps in place to direct staff on where to apply these.” from the report
Fire safety equipment replacement
minorThe fire alarm and emergency lighting were assessed as needing replacement. They were still working, and the provider said replacement was in progress.
“The fire alarm and emergency lighting has been assessed as needing replacement.” from the report
- 01What staff training has now been completed for catheter care, diabetes and falls prevention?
- 02How do you check that staff understand and can safely carry out catheter care?
- 03Are body maps now in place for everyone using topical medicines?
- 04Has the fire alarm and emergency lighting replacement been completed?
- 05What progress has been made against the new manager's improvement plan, and how is this checked?
This was a focused inspection of Safe, Responsive and Well-led after concerns about catheter care and food; Effective and Caring were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 31 May 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 2021
Rated Requires Improvement; inspectors found unsafe infection control, medication and risk-recording practices, and weak management checks.
This was an unannounced inspection on 1 November 2021. Inspectors spoke with five people, four relatives, six staff members and one visiting professional. They reviewed care records, medication records, staff files and management records.
The home was not always safe. Inspectors found problems with infection control, risk assessments, care records and medication. These included incorrect use and storage of protective equipment, missing checks for bed rails, incomplete recording of creams and ointments, and covert medication given without the correct legal safeguards.
The home was also not always well-led. Management checks had failed to identify several of these problems. The overall rating fell from Good at the last inspection to Requires Improvement. The report says there was no evidence that people had been harmed, but the weaknesses placed people at risk.
Protection from abuse
Inspectors found systems to identify abuse and neglect, and the required safeguarding incidents had been reported.
“People were protected from the risk of abuse or neglect.” from the report
Safe recruitment
Staff had the required recruitment checks and received regular supervision.
“Staff were recruited safely. Staff had mandatory recruitment checks in place to ensure they were safe to work with people living at the service.” from the report
Person-centred care
People were involved in decisions and supported with choice and control in the least restrictive way.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests;” from the report
Clean premises
The building was clean and free from unpleasant smells during the inspection.
“The premises were clean, tidy and odour free. Domestic staff cleaned appropriately throughout the inspection.” from the report
Infection control
seriousProtective equipment was not always used or stored safely. Inspectors also found that social distancing was not encouraged during a COVID-19 outbreak and medication pots were not safely controlled.
“Systems did not robustly protect people from the risk of infection transmission.” from the report
Medication safeguards
seriousRecords did not show that creams and ointments were always applied. One person received covert medication without the required legal safeguards or review system.
“We found one person was being given covert medication without the correct safeguards in place.” from the report
Missing risk assessments
seriousRisk assessments were not always completed, including for people using bed rails. This meant the home could not show that risks were being managed properly.
“People's risk assessments were not always in place. For example, not everyone who had bed rails had this risk assessed.” from the report
Weak management checks
seriousAudits and governance checks did not find problems with infection control, medication, environmental safety, care planning and risk management.
“Governance oversight checks failed to identify issues highlighted by the inspection team in relation to environmental checks, safe medication practices and the response to COVID-19.” from the report
- 01What has been changed to make sure staff use and store protective equipment correctly, especially during an infection outbreak?
- 02How do you now check that creams, ointments and other medicines have been given and recorded correctly?
- 03What legal safeguards and review process are in place if covert medication is considered for someone?
- 04Have all missing risk assessments, including assessments for bed rails, now been completed and reviewed?
- 05What new checks make sure management identifies problems with care plans, infection control, medication and environmental safety?
This was an unannounced inspection prompted partly by safeguarding concerns and examined Safe and Well-led; the report does not give separate ratings or detailed findings for the other three key questions. This explanation was written from the published report of 15 December 2021 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 Bilton Hall Nursing Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- August 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 18 February 2011.
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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