The Bill House is a ‘care home’ and is registered to provide accommodation for up to 38 people, some of whom are living with dementia and who need support with their personal care needs. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Bill House is a large property with accommodation over two floors. The home had communal dining areas and lounges. People had access to a large garden overlooking the sea.

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 fo

The Bill House is registered to provide accommodation for up to 38 people, some of whom are living with dementia and who need support with their personal care needs. On the day of the inspection 35 people were living at the service, one person was in hospital. The Bill House is a large property with accommodation over two floors. There were communal lounges, dining areas and access to a garden.

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 b

The inspection took place on 25 January 2016 and was unannounced.

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

Due to their disabilities many of the people accommodated were not able to tell us about their experiences. To help us to understand the experiences people have we used our Short Observational Framework for Inspection (SOFI) tool. This tool allows us to spend time watching what was going on in a service and helps us to record how people spent their time, the type of support they get and whether they have positive experiences.

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.

Due to their disabilities many of the people accommodated were not able to tell us about their experiences. To help us to understand the experiences people have we used our Short Observational Framework for Inspection (SOFI) tool. This tool allows us to spend time watching what was going on in a service and helps us to record how people spent their time, the type of support they get and whether they have positive experiences.

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.”

Due to their disabilities many of the people accommodated were not able to tell us about their experiences. To help us to understand the experiences people have we used our Short Observational Framework for Inspection (SOFI) tool. This tool allows us to spend time watching what was going on in a service and helps us to record how people spent their time, the type of support they get and whether they have positive experiences.

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.”

We spoke with three people who live at The Bill House. Conversation with people was limited due to their mental frailty. However, we spent time with them during the morning as they took part in activities. We also observed the care they received from staff in order to understand what it was like to live at this care home.

We spoke with the relatives of two people who were visiting the care home. They told us they were very happy with the care and support provided. One relative told us, “I was blown away by the friendliness of the staff. Everyone is really nice and professional.”

We spoke with three members of staff who were on duty. They demonstrated they knew about the level of care that each person required and what they were expected to do to ensure their needs had been met. They also told us they were well supported by the manager.

We spoke with the manager who explained how care records have been reviewed and updated. They also told us how the quality of service provision had been assessed and monitored.

We were accompanied by an expert by experience during this visit. An expert by experience has personal experience of using or caring for someone who uses a health, mental health and/or social care service. We asked the expert by experience to focus on how the care home meets people’s social and daytime activity needs.