Archived: Millbrow Care Home

Updated 12 October 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 2, 3 and 16 August and 18 September 2017 and was unannounced.

During the first 2 days the inspection was undertaken by an inspection manager, one adult social care inspector and an expert by experience. Experts by experience are people who have experience of using or caring for someone who uses health and/or social care services. On the third and fourth days of the inspection one inspection manager and two inspectors completed the inspection.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We looked at all of the information which the Care Quality Commission already held on the provider. This included any information the provider had to notify us about. Furthermore, we invited the local authority to provide us with any information they held about Millbrow. We took any information they provided into account.

During our inspection we spoke with the regional manager, the resident experience lead, the registered manager; a visiting registered manager, clinical lead; one activity coordinator; a maintenance person and 14 staff. We also spoke with nine relatives. Although we met with 32 people who lived in the home we were only able to gain the views of 18 people. This was because some people were unable to communicate with us due to their various health issues.

However we also undertook a Short Observational Framework for Inspection (SOFI) observation during lunch time. SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We looked at a range of records including: six care plans; six staff files; staff training; minutes of meetings; rotas; complaint and safeguarding records; medication; maintenance and a range of audit documents.

Updated 12 October 2017

The inspection was unannounced and took place on 2, 3 and 16 August and 18 September 2017.The previous inspection of Millbrow was a focused inspection and was carried out on 29 January 2016 when it was found to require improvement in the safe and well led domains.

Millbrow provides accommodation and personal care for up to 44 people. At the time of our inspection the service was accommodating 42 people.

There was a registered manager in place at Millbrow. 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.

During the inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 related to: person centred care; dignity and respect; safe care and treatment; safeguarding service users from abuse and improper treatment; meeting nutritional and hydration needs, staffing and good governance. We also found a breach of the Care Quality Commission (Registration) Regulations 2009 as the registered person had not always notified the Commission of incidents or allegations of abuse.

Risk assessments and care plan did not always adequately identify and address people’s health and personal care needs. Staff did not always follow actions stated as being required on people’s care plans. People did not always receive safe and effective care.

Allegations of abuse were not always reported or acted on in accordance with local procedures. Medicine management systems were not effective. Medicines were not always stored safely and records were not complete.

Medicine management systems were not effective. Medicines were not always stored safely and records were not complete.

Standards of food hygiene and safety were poor and systems were not robust to prevent the spread of infection.

Agency staff were employed on a regular basis. The process for ensuring that these staff were adequately inducted when they first started working at the home needed improvement.

We saw that people were left without access to drinks for long periods of time and there was as long as a 17 hour gap between the evening meal and breakfast the following day for some people. People’s dietary requirements were not always met and staff had not always supported people effectively with weight loss or gain which presented a risk to their health and wellbeing.

The environment on the first floor, for people living with dementia was poor. There was a lack of visual and tactile stimuli and a lack of signage made it difficult for people to orientate themselves around the home.

People’s personal hygiene was not always attended to in a timely manner. Monitoring charts were inaccurate, as they were not completed contemporaneously. We observed instances where staff recorded that they had attended to people when we could evidence that they had not.

The leadership and governance in the home was inadequate. Quality assurance systems were complicated but failed to identify serious failings in the care people were receiving.

People did tell us that they enjoyed the activities that were arranged at the home. The home employed an activities coordinator who was passionate and enthusiastic about her job.

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.