Bilney Hall

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The registered manager had clear oversight of documented incidents within the service. Incident and accidents were reported and recorded routinely by staff. Staff understood their responsibilities in reporting any concerns. One staff member told us “All accident and incidents are reported to management when they happen. An accident form is completed and submitted to management. It may be that immediate action is required and if so, this is done straight away.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. We spoke with family members who told us decisions had been communicated with them. One relative said, “The manager will always involve the family in what she thinks are in [Family Member] best interests and when a room became available at Bilney Hall we discussed and agreed it would be in [Family Member] best interests that she be moved to that unit as there were more ladies at her stage of Alzheimer’s there.” One external professional said, “Communication from the manager to ourselves has been professional and relevant.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Staff knew how to report abuse and told us they had received safeguarding training. The manager and staff understood how to safeguard people. The manager had a safeguarding log in place and notifications were made to the relevant authorities. People consistently told us they felt safe. One person said, “I feel very safe. The windows and doors are locked, and the staff are here if you need them.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff involved people in managing and understanding their own risks. People told us they are involved planning their care needs. One person told us, “Oh yes, I have been. I was poorly when I came in here so my two sons and my daughter in law went through everything with the home.” One relative told us, “I visit often and will speak of day-to-day issues with staff. Staff always call her if there is a need. They do resident of the month where they phone me and say what checks have been made and how things are going at that moment, but staff always keep me informed and involved.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had effective processes in place to monitor that the environment was maintained and safe. Each person had a Person Emergency Evacuation Plan (PEEP) in place, copies of these documents were in the grab bag in the service. The service also had a business continuity plan in place with contact made available to staff in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We found that staff were recruited safely. Appropriate checks were completed and there were no gaps in the employment history. Staff were supported with their learning and development needs and encouraged to continually improve in their role. One staff member told us, “The training here has significantly improved over the years and is at a very high standard with our new trainer. We do specialist senior training and have outside/extra training offered to us.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home was clean and free of clutter. Staff were observed wearing Personal Protective Equipment during the site visit. The kitchen staff had all appropriate measures in place to ensure the risks of Infection Prevention and Control (IPC) were kept to a minimum. The registered manager had clear oversight of IPC and carried out regular checks and audits in relation to IPC. IPC procedures were in line with the providers policy.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were stored safely and records were completed appropriately. Staff had received training and regular competencies. We observed a staff member administering medicines with a person-centred approach. The staff member took the time to speak with the person and gain consent. One person said, “I have my medicines at breakfast in the dining room. Always spot on.” Another said, “My medication comes regular as clockwork.”