The Bill House

The Bill House is a residential care home in West Sussex providing personal care to 32 people living with a range of needs, including frailty of old age and dementia. The service can support up to 38 people.

People’s experience of using this service and what we found

Concerns had been raised to CQC with regard to some aspects of medicines management. For example, the manager had been unaware of the need to have a member of staff on duty at night who was trained to administer medicines. The manager did not have a clear understanding of when to notify CQC of any abuse or alleged abuse, and this was clarified with them at inspection.

Nevertheless, The Bill House provided a safe, caring environment for people. One person told us they were happy living at the home and of the kindness of staff. Risks had been assessed and actions were taken to mitigate risks. Staffing levels were sufficient to meet people’s needs and new staff were recruited safely. People received their medicines as prescribed.

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; the policies and systems in the service supported this practice.

A robust system of audits had been implemented to measure and monitor the care people received, and to drive improvements. People’s diverse needs were recognised and catered for.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good, (published 18 December 2019).

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Why we inspected

We received concerns in relation to the management of medicines. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Bill House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Bill House is a residential care home providing personal care to 30 older people with a range of needs, including dementia, at the time of the inspection. The home can support up to 38 people.

People’s experience of using this service and what we found

Improvements had been made since the last inspection. People were protected from the risk of abuse and harm by staff who had been trained appropriately and knew what action to take if they had any concerns. Risks to people had been identified and assessed, with guidance for staff on what actions to take, which was followed. Staffing levels were sufficient to meet people’s needs and new staff were recruited safely. Medicines were managed safely. The home was clean and smelled fresh.

Before people came to live at the home, their needs were assessed, to ensure the home could provide the level of care they required. A relative of one person said they had looked at many homes before deciding that The Bill House was the right place for their loved one. People received care from suitably trained staff and were encouraged in decisions relating to their care. 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; the policies and systems in the service supported this practice.

People were supported to eat and drink in a healthy way and had a choice of menu; specialist diets were catered for. When people became unwell or needed support from a healthcare professional, they were seen or referred to the relevant professional.

Staff were warm, kind and caring with people. People’s diverse needs were identified and catered for, so that care was delivered in a personalised way to meet people’s preferences. People were treated with dignity and respect.

Care plans were detailed and reviewed with people and their relatives. People’s personal histories were recorded, including their preferences, and activities were planned to meet these. People’s communication needs had been identified, so that staff communicated with them in a way that suited them. Complaints were managed in line with the provider’s policy. If it was their wish and people’s needs could be met, they could live out their lives at the home.

People were happy living at the home and their relatives spoke positively about the home, and of the registered manager and staff. Feedback was obtained through questionnaires. Staff felt supported by the registered manager. The service worked in partnership with others to benefit people’s care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection.

The rating at this service was requires improvement (published 17 November 2018). The overall rating has changed from requires improvement to good. This is based on the findings at this inspection.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The inspection took place on 20 September 2018 and was unannounced. On the day of the inspection there were 27 people were living at the home. The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 11 January 2018, the home received a rating of 'Requires Improvement' and was found to be in breach of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions to at least good. This was because there were concerns that people were not being treated with dignity and respect at all times, care and treatment was not always provided with the consent of the relevant person, care was not always provided in a safe way for people and the registered manager had not always ensured good governance of the home.

At this inspection we found that the registered manager had made significant improvements to the management of the home and they were no longer in breach of the Health and Social Care Act (Regulated Activities) Regulations 2014. However, we did identify some areas that need improvement. This is the second consecutive time the home has been rated as ‘Requires Improvement.’

Risks to people, in relation to falls, were not consistently assessed, mitigated or known by staff. Staff understood what action to take in the event of an incident and followed internal procedures for reporting and documenting these. The registered manager's approach to quality assurance was inconsistent and systems did not always identify issues in service delivery.

People gave mixed feedback about staffing levels. One person told us, “There are enough staff.” However, another person told us, “The response to my calls is usually good but at weekends the response is less good.” At the inspection staffing levels were consistent, including weekends, with the numbers the registered manager told us were required. we observed staff to be responsive to people’s needs and respond to people’s requests in a timely manner.

People had inconsistent access to meaningful activity. People provided mixed feedback about the activities available at the home. We observed staff to engage well in activities with some individuals whilst others spent long periods sat in communal areas with little interaction.

People were protected from the spread of infection and the home was clean. People were happy with the cleanliness of the home. There were safe systems in place to manage, administer, store and dispose of medicines. Staff received safeguarding training and knew the potential signs of abuse.

Staff had a good understanding of MCA and had received training in this area of practice. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the home supported this practice. The home was adapted to meet the needs of people. The registered manager had acted to make the environment more accessible for people living with dementia.

People were supported by staff with the skills and knowledge to deliver effective care and support. Staff received training in relation to the needs of older people. Staff understood people's dietary requirements and preferences. People had access to healthcare professionals as and when they needed them. Staff knew people well and monitored their health on a daily basis.

People were treated with kindness and compassion. One person told us, “Staff are very nice, they are always very kind.” We observed positive interactions between staff and people. Staff had a good understanding of people's backgrounds and interests and knew people well. People and their relatives told us they could express their views and be involved in making decisions about their care. One person told us, “Staff do talk to me about my care.” A relative told us, “I was involved with her care plan at the start.”

People's independence was promoted and their privacy and dignity was respected. Staff knocked on people's doors before entering their rooms and waited for people's consent before supporting them.

Care being received was person centred and responsive to people’s needs. People's care plans contained detailed information about the person's life history, preferences and ways in which they liked to be supported. Records evidenced that when people were unwell medical attention was sought in a timely manner.

People were offered the opportunity to plan for the end of their lives. Discussions had taken place with people and their families about their end of life care wishes. The provider ensured there were systems in place to deal with concerns and complaints. People had access to the provider’s complaints policy.

People and relatives were complimentary of the management of the home. One person said, “I do like the manager, she helps out”. A relative told us, “I can approach the manager about anything.” People, their relatives and staff were involved in the running of the home.

Staff worked in partnership with several other agencies to ensure people’s needs were met in a timely manner. The registered manager had a clear vision for the home and told us this centred around respect. We observed these values to be embedded within the service, staff were respectful and treated people as individuals.

We carried out the previous comprehensive inspection on 25 January 2016. The overall rating at this inspection was Good. There was a breach of regulation related to safe care and moving and handling techniques. Following the inspection, the provider sent us an action plan, telling us staff would receive training and supervision in this area and observations of moving and handling procedures would be commenced. During this inspection, we had no concerns about how people were supported to move by staff however, we found concerns related to infection control, aspects of safety within the service, and aspects of medicine management. We also had concerns related to staff following the Mental Capacity Act, staff training, care planning and record keeping, respecting people’s dignity and the governance processes in place at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives told us staff were caring and kind. Most people told us they liked living at the service and were happy. Professional feedback was positive about the registered manager, staff and service provided. Staff demonstrated kindness and compassion for people through their conversations and interactions we observed. However, we saw people’s dignity was not always promoted and they were not always actively involved in making choices and decisions about their care and treatment.

People were protected from abuse because staff understood what action to take if they were concerned someone was being abused or mistreated. Relatives confirmed they felt their loved ones were safe.

Risks associated with people’s care and living environment were not always effectively managed to ensure people’s freedom was promoted. We were concerned that communal bathrooms were locked and people did not have access or keys to their bedrooms. We found some windows did not have restrictors in place and a small kitchenette was left unstaffed at times which could pose a risk. We also had concerns that at the time of the inspection there was no record of external visitors to the service. This meant in the event of a fire, it would have been unknown who was in the building.

We found areas of the home were not clean and best practice in relation to infection control was not followed.

People and their relatives were encouraged to be part of the care planning process and to attend or contribute to discussions about care where possible. However, these discussions were not always well recorded or reflected in people’s care records. Some support plans were out of date so did not reflect people’s current needs. We also found end of life care plans required developing to reflect people’s needs at this time in their life.

People were supported by consistent staff to help meet their needs in the way they preferred. However, it was not always clear if people were given a choice of male or female staff when they required support with personal care.

The registered manager and provider wanted to ensure the right staff were employed, so recruitment practices were safe and ensured that checks had been undertaken.

People’s medicines were mostly well managed. However, some people had medicines without their knowledge and the processes which are required to be followed to administer medicines in this way were not always followed.

People received care from staff who had undertaken the provider’s essential training programme, but training to meet people’s specific health needs for example diabetes and epilepsy were not in place at the time of the inspection. Not all staff had undertaken dementia training.

People’s human rights were not always protected because the registered manager and staff did not have a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. We found the systems in place to record people’s capacity and decisions made in relation to care and treatment required improvement.

People’s nutritional needs were met because staff followed people’s support plans to make sure people were eating and drinking enough and potential risks were known. However, an overview of people’s total fluid intake goal was absent and at the inspection there was a lack of choice available and how to support the nutritional needs of people living with dementia. People were supported to access health care professionals to maintain their health and wellbeing.

Policies and procedures across the service were being developed to ensure information was given to people in accessible formats when required but at the time of the inspection these were in there infancy. Staff adapted their communication methods dependent upon people’s needs, for example using simple questions and information for people with cognitive difficulties and we were told information about the service was available in larger print for those people with visual impairments.

People and relatives felt comfortable raising any concerns and felt confident these would be addressed promptly. We were told people were asked for their views but the recording of these decisions was not apparent for example communal bathrooms being locked, access to bedrooms and involvement in menu discussions. Relatives felt welcome at the service and visiting was not restricted.

The service was led by the registered manager. They received support from the regional manager and provider. The quality assurance systems in place had not identified the areas of concern we found during the inspection however these were under review following inspection feedback. The registered manager and provider promoted the ethos of honesty and admitted when things had gone wrong.

We have made recommendations in relation to the environment and staff training.

We found four breaches of Regulations. You can see what action we told the provider to take at the back of the full version of the report.

The Bill House provides care and accommodation for up to 38 people and there were 36 people living at the home when we inspected. These people were all aged over 75 years and were all living with dementia.

All bedrooms were single and each had an en-suite toilet. There were several communal lounge and dining areas which people were observed using. A passenger lift was provided so people could access the first floor.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff were trained in moving and handling but we observed one instance where staff failed to follow safe moving and handling procedures.

Staff were trained in adult safeguarding procedures and knew what to do if they considered people were at risk of harm or if they needed to report any suspected abuse. People said they felt safe at the home.

Care records showed any risks to people were assessed and there was guidance on how those risks should be managed to reduce any risk of harm.

There were sufficient numbers of staff to meet people’s needs. Staff recruitment procedures ensured only those staff suitable to work in a care setting were employed.

People received their medicines safely.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Staff were trained in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). People’s capacity to consent to their care and treatment was assessed and referrals were made to the local authority where people’s liberty was restricted for their own safety.

There was a choice of food and people said they liked the food. The provider consulted people about the food and meal choices.

Staff were skilled in working with people who were living with dementia and had access to a range of relevant training courses to enable them to meet people’s individual needs.

People’s health care needs were assessed, monitored and recorded. Referrals for assessment and treatment were made when needed and people received regular health checks.

Staff were observed to treat people with kindness and dignity. People were able to exercise choice in how they spent their time. Staff took time to consult people before supporting them and showed they cared about the people in the home.

Each person’s needs were assessed and this included obtaining a background history of people. Care plans showed how people’s needs were to be met and how staff should support people. Care was individualised to reflect people’s preferences. Relatives and a health care professional said the staff provided a very good standard of care.

Staff supported people with activities and there were two activities coordinators to provide and facilitate a range of activities.

The complaints procedure was provided to people and their relatives. People said they had opportunities to express their views or concerns, which were listened to and acted on. There was a record to show complaints were looked into and any actions taken as a result of the complaint.

There was a culture which reflected an open and caring approach to people and their relatives.

Staff demonstrated values of treating people with dignity, respect and as individuals. Relatives’ views were sought as part of the service’s quality assurance system. Relatives commented on good communication with the staff and registered manager. Staff views were also sought and staff were able to contribute to decision making in the home.

A number of audits and checks were used to check on the effectiveness, safety and quality of the service which the provider used to make any improvements.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We spent 40 minutes watching care and support being provided to three people over the lunchtime meal. We observed people being served and helped with the main meal of the day and with cold drinks. We found that people received the support and attention they needed in order to eat and drink sufficiently for their needs. We also observed that people being helped experienced a calm and relaxed mealtime.

We spoke with two members of staff who were on duty. They demonstrated they were knowledgeable about the needs of identified people and the care that needed to be delivered to ensure they had been met.

We also looked at the care records of identified people. They demonstrated that their support needs had been recorded to ensure care staff knew what was expected of them to ensure they had been met.

We spent 30 minutes watching care and support provided to three people over the lunchtime meal. We observed people being served and helped with the main meal of the day and with cold drinks. The pace of the meal had been dictated by the member of staff. The people being helped did not experience a calm and relaxed mealtime.

The atmosphere during the rest of the inspection was good. It was friendly and homely. We observed staff on duty had a good relationship with the people living there.

We spoke with three members of staff who were on duty. They demonstrated they were knowledgeable about the needs of identified people and the care that needed to be delivered to ensure they had been met.

We spoke with a relative who was visiting at the time of the inspection. They informed us that they were very satisfied with the care and support their relative had received. They told us, 'I am very pleased. I am very happy with the way my relative is looked after. ' They also said, 'The care staff are very friendly, very capable and very caring.'

We spent 45 minutes watching care and support provided to five people. We observed people being served and helped with hot drinks. We also observed people participating in activities such as reading, listening to music and talking to care staff. We found that people had positive experiences. The care staff on duty knew what support they needed and they respected their wishes if people wanted to be left on their own. However, what we found was that consent and best interest decisions were not in care records. Therefore, staff placed people at risk of inconsistent care or the care that had been delivered may not have been according to each individual's wishes.

We spoke with a relative who was visiting the care home. They told us they were very satisfied with the service provided and the delivery of care. They told us, 'I consider that my relative is very lucky to be here. The care home is very family orientated; it feels very friendly. The staff are very friendly and very kind. I'm always made welcome when I visit.'