Mill House

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

The service was not safe and remains inadequate. Not enough improvements had been made. We identified 1 breach of the legal regulations. People did not receive safe care which had resulted in harm for people. Care plans and risk assessments were not always in place when needed or followed to keep people safe. Managers and leaders were not aware of risks people were exposed to. The systems in place to monitor people’s safety were not effective and this had exposed people to harm.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We discussed with the manager concerns around a fall a person had recently had and how they were mobilising. They were unable to provide us with an explanation as to why professional advice was not followed and they were not aware of the information within the daily notes that showed staff were not following the care plan. They were also unable to explain or demonstrate they had considered the person’s poor mobility post fall could be linked to the fall. When people were displaying periods of emotional distress the manager told us no plans were in place for this, and these had not been completed since our last site visit. The manager and staff confirmed they were not aware of, and no action had been taken in relation to a person losing a significant amount of weight. The manager also confirmed no action had been taken when a person had a wound, and this had deteriorated. The manager told us they were not able to action our concerns during the site visit as they were not supernumerary and counted in the care numbers. We did not speak with the provider during our site visit as they were not available. We wrote to the provider after we left the premises seeking reassurances but were not assured by the provider’s response as the immediate risks were not adequately addressed. We requested further information from the provider the following day, we did not receive a response.

We observed staff were not following people’s care plans and risk assessment. For example, a person who had recently fallen was not mobilising in line with their care plan, placing them at risk of further falls. We observed a person inappropriately touch another person whilst they were sitting next to them, exposing them to harm. We informed staff of this, but no action was taken, and they continued to be seated next to each other. This meant staff had not responded to risk which placed this person and others at an increased risk of harm. We saw one person was mobilising independently with no support from staff and they were not wearing footwear during these times. This was not in line with this person’s care plan and placed them at increased risk of falls.

The systems in place to keep people safe were not effective and people were placed at risk of harm. There were no systems in place to monitor mobility and falls. We saw the care plans in place were not followed, exposing people to the risk of falls. A fall had occurred in the home, the person had seen paramedics who had advised for the GP to review this person. This had not been completed and the person was experiencing issues with their mobility. This had not been identified and no action had been taken. When people had displayed periods of emotional distress, we saw not all incidents were documented. We found the same concerns at our last site visit. There was not always guidance, care plans or risk assessments to show how to support people during these times and these incidents continued to occur. People had received injuries during these times, meaning people had been exposed to harm. The systems in place to monitor weight loss or wounds were not effective. We found 1 person had lost a significant amount of weight, but this had not been identified and no action taken. Another person had a wound which had deteriorated, and no action had been taken.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.