The inspection took place on 23 November 2017 and was unannounced. Our last inspection was in September 2016 where we found no breaches of the legal requirements, but we rated the service as Requires Improvement as recent improvements had not become embedded and sustained.Milner House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Milner House accommodates up to 46 people across two floors, each of which have separate adapted facilities and some shared facilities. People living at the home had a variety of medical conditions and healthcare needs. Most of the people at the home were living with dementia. At the time of our inspection there were 24 people living at the home.
There was not a registered manager in post, one of the provider’s operational managers was in the process of registering with CQC at the time of inspection. 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 did not always receive their care safely. We observed two instances in which staff used inappropriate moving and handling techniques when supporting people. Prescribed equipment was not used which placed people at risk of injury. Where risks were identified, we found that staff were not always implementing plans to keep people safe.
Where incidents and accidents had occurred, the measures put in place to reduce the risk of them happening again were not always implemented robustly. There were not sufficient numbers of staff present to safely meet people’s needs. We observed that where people required supervision as a part of their risk management plans, staff were unable to provide this due to being busy elsewhere.
Care was not always delivered in a dignified way. Half of the people that we spoke with told us that they had encountered staff that appeared reluctant to provide support to them. People said this was a particular problem at night time and this impacted on their wellbeing significantly. There were high numbers of temporary agency staff employed at the home and they did not always know people’s needs well. People reported that staff did not take due care with their belongings and there weren’t effective systems in place to ensure people’s belongings returned from the laundry. The laundry lacked organisation and we found that linen was not stored in a way that guaranteed it would not become contaminated.
There was a lack of good practice in relation to infection control. Where infection control risks were known about one person’s medical condition, a plan was not recorded to guide staff on how to prevent cross-contamination. Staff were also observed failing to follow good practice when supporting this person. Areas of the home were not clean and systems to prevent cross-contamination were not implemented correctly.
People’s medicines were not always managed safely. Discrepancies in medicines records had been identified in an audit by the provider, but had not been addressed. We also found shortfalls in the way that medicines were stored and monitored. Nursing staff did not receive the clinical supervision that they needed and there was a lack of leadership at the home. Staff were not held to account for work that they completed and there was a lack of oversight from the provider.
People did not always receive person-centred care. Care plans contained person centred information, but we identified occasions where things that were important to people were not documented in their care plans. People told us that the activities they were offered did not cover the whole week and they often felt bored at weekends. We observed some activities taking place and saw evidence of good practice in this area, however people fed back that there was a lack of consistency.
There was a lack of leadership and governance at the home. We identified information missing from records and the provider’s audits had not identified or addressed the numerous concerns we found during our inspection.
Checks had been undertaken on new staff as well as agency staff to ensure they were suitable for their roles. Staff understood their roles in safeguarding people from abuse, however we found people were not always comfortable raising their concerns. Where complaints or concerns were raised, the provider responded to them. We recommended that the provider reviews their record keeping of complaints.
People were offered a choice of foods that reflected their dietary needs. We identified some shortfalls in the record keeping in the kitchen and recommended that the provider reviews their systems for involving people in choices about their meals. We saw evidence of people being supported to access healthcare professionals when required.
Staff followed the guidance of the Mental Capacity Act (2005). We observed times where people’s privacy was respected by staff and we received some positive feedback about staff at the home. There was a contingency plan in place to be implemented in the event of an emergency. The provider had systems in place to reduce the risk of fire and to respond in the event of an emergency. The provider had developed links with the local community that had impacted positively on people.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.
Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.
The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.
If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.
For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.