Milverton Road

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. Based on the findings of this assessment the rating for this key question has changed from good to requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed. This was because we found concerns with medicines management. These failures had placed people at risk of harm under 1 breach of Regulations. Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We discussed concerns relating to medicine management and governance with managers and requested for some immediate assurances. They were able to provide some additional evidence of how outstanding issues had now been met. You can find more details of our concerns in the evidence category findings below.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers and staff told us incidents and accidents were recorded on the system, this included any safeguarding concerns or complaints. These were analysed and reviewed to determine any underlying causes and identify any remedial action or improvement actions. Staff told us that team meetings were used to share information about any incidents along with any learning. However, we found delays in the reporting and investigating of incidents and safeguarding concerns and insufficient action was taken to ensure people were kept safe. Our findings were further corroborated with the Local Authority who informed us the service did not always listen to concerns about safety and did not always report safety events in a timely manner.

The service did not always learn lessons when things went wrong. For example, the service completed 3 monthly audits. Though we saw some evidence of actions taken to prevent reoccurrence of incidents and lessons learnt being recorded. We did not see actions taken as a result of some of the shortcomings. Despite internal audit identifying some concerns in August 2024 and a subsequent external audit by the Local Authority in September 2024 also highlighting similar issues, we found little improvements were implemented to address these matters as we found comparable concerns on our site visit day in November 2024. The service had not always identified and taken necessary and reasonable action to address areas that required improvement. The service did not operate effective systems for assessing, monitoring, and improving the quality of the service and mitigating risks to people’s safety. As a result, the service did not have effective and robust systems to ensure that people were always receiving safe and appropriate care.

Managers informed us they planned and organised care and support with people, together with partners and relatives in ways that ensured continuity. Staff were aware of the signs to look out for and the action they needed to take to minimise risks to people.

The Local Authority told us the service did not work well with health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people’s care and support needs changed.

The service did not always maintain safe systems of care. Care plans and risk management plans were in place for everyone living at the care home. We found care plans to contain a considerable amount of information that could hinder accessibility, leading to vital information being overlooked. We found some aspects of care plans to be generic and not person centred, for example, epilepsy care plans and associated risk assessments had the same generic information on managing seizures even though their epilepsy may present in different ways. We also found discrepancies in the recording of allergies in one care record, posing a potential risk of the person being prescribed medicine which they are allergic to. These inconsistencies pose a probable risk when inducting new staff, agency staff or transferring people between services, leading to potential risk of harm being caused. We discussed these findings with management who informed us of their plan to implement a digital care and support planning system in January 2025. This is expected to improve documentation practices and accessibility ensuring that critical information is more readily available.

Staff were aware of safeguarding procedures. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm.

We observed how people using the service interacted with staff and they looked at ease and comfortable in staff’s presence.

The provider had clear safeguarding and staff whistleblowing policies and procedures in place which were kept up to date, reflected relevant legislation and were easy for staff to access. However, the service did not always effectively implement their policies and work well with people and partners to understand what being safe meant to them and how to achieve that. Although staff we spoke with had sound knowledge of safeguarding procedures, there appeared to be a disconnect in applying this to practice. We found a significant delay in the reporting of a safeguarding concern and the services response in investigating the concern was not satisfactory. The Local Authority reported delays in the service’s response to reporting safeguarding concerns. and a failure to recognise certain incidents as a safeguarding concern. Local Authority informed us it was not always clear what measures the service had put in place to minimise risks or prevent recurrence of incidents. The service did not always share concerns quickly and appropriately.

The service had a staff team, most of whom, were familiar with people’s daily routines, preferences, and risks. Staff were able to provide examples of when they have identified situations where people may be at risk and how they responded to manage those risks.

We observed staff supporting people in a safe way throughout this assessment visit. Staff were observed using the correct moving and handling equipment to support people with transfers and mobility.

Risk management plans were not always updated to reflect any changes in people’s needs. Care records did not always meet people’s individual needs that kept them safe. We found discrepancies in care records, for example one record had discrepancies in care plans and administration charts for the level of support required to manage dysphagia (difficulty swallowing). There was a risk that the person was put at an increased risk of choking. Risk assessments were generic and did not contain person specific information in identifying individual signs and triggers. There was a risk that agency staff and other healthcare professionals would not have the person-centered information to identify when people were in pain for example. Additionally, not all doses on PRN protocols for pain management matched what was prescribed for the individual person. There was a risk that people could receive incorrect doses of medicines if the PRN protocols were followed, and pain would not be appropriately managed.

Managers and staff told us people lived safely in the home which had been suitably adapted to meet people’s individual needs and wishes.

The service environment was well-maintained, with a good standard of hygiene and cleanliness in people’s rooms and communal areas.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service completed regular health and safety checks of the building including gas safety and water systems. The service had an up-to-date fire risk assessment in place for the building and personal emergency evacuation plans (PEEPs) in place for all people living at the care home. The environment had adaptations and reasonable adjustments in place to meet people’s individual needs.

The service had a 37.5% decline in staffing levels over the year which raised concerns about the potential impact on the continuity of safe and effective care to the people they support. Management told us proactive recruitment efforts have been underway to fill vacant posts. The service had been able to cover shifts with agency staff. Annual staff feedback report found that most staff would agree that the service promoted workplace wellbeing and felt equipped with the necessary skills to do their job well. We saw evidence in supervision records of training and development being discussed, in addition to workload and wellbeing check-ins. However, some staff we spoke with, expressed concerns with the recent drop in staffing levels having an impact on workload and work culture. This view was also reflected in their annual staff feedback report. Additionally, some staff we spoke with reported working long shifts of 14 hours without adequate break time. Team meeting minutes indicated that a designated break room is available for staff to take their breaks, and staff also had the option to leave the service for their break. We looked at the shift allocations during the day of the on-site visit and found allocated break times for staff were not recorded. Management told us all staff were actively encouraged to take their break, and that cover was available during these times. Management acknowledged that while some staff may be comfortable working long days, others may not share this preference, and this will be reviewed. We also noted the transition time between shifts did not include time for handover. We discussed with management establishing a dedicated overlap period to allow enough time for adequate handover.

We observed staff were visibly present throughout our on-site visit. Staff demonstrated good engagement with the people they supported and were attentive to their needs, which included preparing meals and drinks, supporting with eating and drinking and safe moving and handling practices.

We checked 3 staff recruitment files and saw that all appropriate processes and checks were in place. The service conducted enhanced disclosure and barring service (DBS) checks., which provided information including details about convictions and cautions held on the Police National Computer. The information helped the service make safer recruitment decisions. The service had mandatory training and induction checklist in place for all new starters. The registered manager is accountable for ensuring the pathway is completed by new staff members and signed off. Training records showed that staff received ongoing training that was appropriate for their role. Training records for the service indicated 100% staff training compliance in mandatory areas including Learning Disabilities, Moving and Handling, Health and Safety and Infection Prevention and Control. We saw evidence in team meeting minutes of refresher training being provided to all staff, the service recently had refresher training in Safeguarding. Supervision records showed all staff had regular supervision meetings with the registered manager to support them in their role and to identify any further training or learning they might need. There were systems for the service to identify and monitor staff training and supervision requirements and ensure it remained relevant and up to date. Furthermore, we saw a recent change in the duty rota that took place in November 2024 where the service had implemented 2 waking night staff as opposed to 1 waking night and 1 sleep in. Feedback from staff we spoke with indicated this is a positive change.

Managers and staff told us they had received up to date infection control training.

The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. We observed Staff following current best practice guidelines regarding infection prevention and control. Hand gel was available at different points throughout the service, making it accessible to maintain good hand hygiene.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. For example, the service had a recent infection outbreak that prompted notification to the local Health Protection Team and other relevant agencies. The service implemented appropriate measures to manage and mitigate risks. Staff and management told us that the service was regularly cleaned. Staff checked, maintained, and cleaned equipment daily, this was reflected in cleaning records.

All staff who administered medicines received training and were assessed as competent. They told us they felt supported and received enough training to safely carry out their role.

Medicine administration and governance was not managed safely in line with best practice. PRN protocols did not accurately reflect the prescribed doses of PRN medicines for people they support. There was a risk that people could receive incorrect doses of medicines if pro re nata (PRN) protocols were followed. Additionally, we could not be assured that thickeners were being administered in-line with the speech and language therapy care plans. We saw discrepancies in care plans and medication administration records (MARs) charts, placing people at potential risk of choking. We also saw time sensitive medication was not always administered as prescribed. Due to the associated risks to the people who reside at the service, this is a breach of regulation 12 safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider for immediate assurances. Care plans did not always accurately reflect the person’s medicines. We saw in one care record, that medicine was listed incorrectly. We saw discrepancies in the recording of medicine in some people’s “grab and go” sheets. Additionally, we saw gaps in MARs. Whilst staff provided some verbal assurances, the recordings were not in-line with best practice guidance or the services policy. Furthermore, the latest medicine audit identified issues with the recording of allergies on MARs. We found similar issues during the on-site visit. Therefore, we did not see evidence of actions taken because of this.