Archived: Milverton Gate Care Home

When we inspected the home in October 2015 we found there were four breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014. These breaches were in relation to: the safe care and treatment people received, ineffective medicine management, people’s nutritional needs not being met, and insufficient quality monitoring of the service. There were also not enough suitably qualified, experienced staff to meet people’s care and treatment needs.

At the following inspection on 1 March 2016, sufficient improvement had been taken in response to the breaches in regulations but there were still areas which needed further improvement.

At the last inspection on 4 April 2017 we found previous improvements had not been sustained. The provider was again in breach of the legal requirements and regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to take the necessary action to improve. This included improvements to staffing arrangements, the notification of specific incidents (such as incidents that impacted on people’s safety) and improvements to the management of the home.

Although the provider had an action plan in place to address these areas, when we carried out this inspection on 21 November 2017, we found action taken had not been effective in making and sustaining the required improvements. The breaches in the regulations from the previous inspection in April 2017 continued. In addition there was a breach of the Care Quality Commission (Registration) Regulations 2009.

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.

There has been no registered manager at the home for since February 2017. 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.

Milverton Gate care home has had different interim managers supporting the home in the last 12 months. There had been changes in the provider’s regional managers supporting the home. This had resulted in inconsistent managerial oversight of the home which staff told us they found challenging. When we carried out this inspection, a new manager was in post and had been working at the home for one week. People and staff were still getting to know the new manager and new regional manager but initial feedback from people was positive.

People and their relatives told us staff were not always available when people needed them and we found this to be the case. Throughout the day we saw some people received delayed care because staffing arrangements were not sufficient and effective. At mealtimes, there were not enough staff available to support people with their meals in a timely manner.

The provider had not ensured people received consistent safe care and treatment. We found serious risks associated with people’s care had not always been identified by the provider and staff. This placed people at risk of ill health. Records available did not always show how risks, such as those related to skin damage, were to be managed or stated how they had been managed.

Quality monitoring systems to assess, monitor and mitigate risks were either not in place or were not effective. Some serious incidents and accidents had not been investigated thoroughly, or reported to us and the local authority as required, to make sure health and safety risks to people were managed. There were some risks associated with the environment such as exposed hot pipes and a hot food trolley which had not been identified during audit checks of the home. This meant the risk of burns to people had not been assessed so they could be prevented.

Some people and their relatives were not aware of meetings they could attend to discuss the home. They were also not aware of questionnaires they could complete to offer their opinions of the home. There was a complaints procedure on display stating how people could raise a concern. There had not been any recent complaints received at the home.

Staff completed training to update their skills and knowledge but new staff had not consistently completed the induction training planned. Supervision meetings had not taken place since the last inspection to support staff in their role.

Staff lacked an understanding of the Mental Capacity Act despite having completed training on this. People were not always asked for their consent before care was provided. The requirements of the Deprivation of Liberty Safeguards (DoLS) were not met as people had not been referred to the appropriate authority for an assessment when they thought the person’s freedom was restricted. There was no effective process to determine people’s capacity where decisions needed to be made in people’s best interest.

Medicines were not always managed effectively to ensure people received them as prescribed. The new manager had recently implemented regular checks of medicines to make sure this was safe.

Arrangements were in place to ensure people could access healthcare professionals. Staff made contact with the GP when necessary to ensure referrals for dieticians, the speech and language team, and other healthcare professionals could be made.

People looked well presented with clean clothes to maintain their dignity. Staff knew about practices they should follow to respect people’s privacy and dignity. Most staff interactions were kind and caring but we saw they had limited time to engage with people and did not always have time to sit and talk with them. Some social activities were provided at the home but these were not always in accordance with people’s interests and hobbies.

The provider had taken immediate steps to ensure a new manager was recruited when the previous manager left. The provider had increased the number of quality checks at the home. We found some actions in response to improvements needed were still to be implemented. The provider’s management team were at the home on the day of our visit. They were open and honest regarding areas needing improvement and felt the actions they had planned would address these.

Shortly after this inspection visit, the provider sent us an action plan outlining the actions they were taking to address some of the issues we highlighted and they stated they would keep us updated about improvements made. The provider told us they had carried out a further review of staffing arrangements to ensure these were sufficient and stated they would not be accepting further people into the home until they had improved.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

When we inspected the home in October 2015 we found there were four breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014.

These breaches were in relation to the safe care and treatment people received; medicines were not administered accurately and at suitable times to make sure people were not placed at risk. People did not always adequately receive food and fluids to sustain their health and the provider did not continually assess, monitor and improve the quality of the service. There were also insufficient numbers of suitably qualified, experienced staff to meet people’s care and treatment needs.

At our last inspection on 01 March 2016 we checked improvements had been made. We found sufficient action had been taken in response to the breaches in regulations. However, there were some areas where further improvements were required and the provider had plans in place for on-going improvements to be made.

At this inspection we found the improvements made had not been sustained and the provider was again in breach in the legal requirements and regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014.

The home did not have 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.

Since our last inspection the manager had left and three separate interim managers had been supporting the home; there had also been two changes in the regional manager. This meant the home had not had a consistent managerial oversight. Continued changes in management had affected staff confidence and staff found this unsettling. The provider had recently recruited a new manager and a deputy manager and people, relatives and staff spoke positively about the new managerial team.

The provider had relied on high levels of agency staff as several permanent staff had left. This meant people did not consistently receive support from staff who they were familiar with and knew how people liked to receive their care. Some people and their relatives told us at times staff were not always available when people needed them. The provider had recently recruited permanent nursing and care staff to the service.

During our visit, most people’s call bells were in reach but we still found three people who did not have access to theirs. We saw when people used them, staff mostly responded in a timely manner, however we observed one call bell took eleven minutes for staff to respond.

The provider did not consistently ensure people received safe care and treatment. Some risk assessments had not been fully completed and some staff did not consistently follow instructions contained in the risk assessment. Where risks were identified, for example where people were at risk of skin breakdown due to pressure or at risk of choking, most staff followed guidelines and correctly used specialist equipment to minimise risks.

Incidents and accidents were not consistently investigated thoroughly and the provider had failed to notify us, and the local safeguarding team, of notifiable events within the home. Staff we spoke with had an understanding of their responsibilities in relation to safeguarding.

Some people did not receive their medicines at times when they needed them. We found most medicines were administered, stored and disposed of correctly, however we identified some gaps on people’s medication administration records (MARS). Some people required their medicines “as required” (or PRN) and protocols were not always available in people’s medicine plans. Some care records did not evidence how their pain levels were formally being monitored or assessed.

People, healthcare professionals and visitors were mostly complimentary of the permanent staff and the care provided at the home. We saw staff engaged well with people. Most people looked well presented with clean clothes and hair and people’s privacy and dignity was promoted. Relatives and friends were able to visit the home at any time.

Staff were kind and caring to people, but did not always have time to sit and talk with them. Most interaction with people who lived at the home was whilst staff carried out personal care tasks.

People mostly received the food and fluids they required to maintain their health although some people told us they did not always have drinks available to them. The home worked well with the dietician, GP, speech and language team, and other healthcare professionals to support people with their healthcare needs.

Most people and their relatives were happy with the care provided, but some felt staff did not respond to their needs as quickly as they would like. People told us staff respected their privacy.

The requirements of the Deprivation of Liberty Safeguards (DoLS) were not always met. The provider had referred people to the local authority for an assessment when they thought the person’s freedom was restricted and when they had been assessed as not having capacity to consent to this. However one application had not been submitted and some aspects of the Mental Capacity Act had not been acted on.

The provider had taken steps to improve the standards in the home by recruiting new staff, motivating existing staff, and was keen to promote an open and transparent culture. The new regional manager supported the managerial team and the provider’s resident experience team (RET) was supporting the new manager and providing additional training to staff.

Regular quality audits of the home had not been consistently conducted to monitor and improve the care provided by the service however the provider was addressing this.

The provider’s managing director and management team were open and honest regarding the challenges the home had been through and acknowledged that improvements were required. They were taking positive steps to address the issues we identified and to provide support to the new manager and staff to ensure stability for the home.

We found three breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014.

Shortly after our inspection the provider sent us an action plan outlining the actions they were taking to address the issues we highlighted and continued to keep us updated of improvements being made.

At our last inspection on 14 October 2015 we found there were four breaches in the legal requirements and Regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014.

These breaches were in relation to the safe care and treatment people received; medicines were not administered accurately and at suitable times to make sure people were not placed at risk. People did not always adequately receive food and fluids to sustain their health and the provider did not continually assess, monitor and improve the quality of the service. There were also insufficient numbers of suitably qualified, experienced staff to meet people’s care and treatment needs.

As a result of the inspection the home was put into special measures. We asked the provider to improve staffing arrangements; ensure people received safe care and treatment; ensure people received their medicines accurately; ensure people received the food and fluids required to maintain their health; and improve their quality assurance systems and how the home was managed. The provider sent us an action plan and regular updates to tell us about the improvements they had implemented.

Following the inspection the provider placed a voluntary stop on admissions to the home in order to address the issues we had highlighted.

At the inspection on 1 March 2016, we checked improvements had been made. We found sufficient action had been taken in response to the breaches in Regulations. However, there were some areas where further improvements were required and the provider had plans in place for on-going improvements to be made.

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.

Since the October inspection, the provider had reduced the number of agency staff who worked in the home, and staffing levels at the home had increased. The home was fully staffed according to the provider’s staff dependency tool. This ensured people received support from staff who they were familiar with and knew how people liked to receive their care.

Staff were available at times when people needed them; however staff from the activities team were sometimes involved in providing personal care, and other tasks to people, which took them away from their main duties.

The provider had made improvements to ensure people received safe care and treatment. Where risk were identified, for example where people were at risk of skin breakdown, or at risk of choking due to a medical condition, staff followed re-positioning guidelines and correctly used specialist equipment to minimise risks.

Following our inspection 1 March 2016 we found the provider had failed to notify us, and the local safeguarding team, of an incident involving a person who had unexplained bruising. They had notified us of other notifiable events within the home.

At our last visit 14 October 2015 many people who could use a call bell to request assistance, did not have one in reach. During our visit 1 March 2016, most people’s call bells were in reach but we still found three people who did not have access to theirs. We saw when people used them, staff responded quickly.

The provider had made improvements in how medicines were managed and administered. People received their medicines at times when they needed them and were given pain relief before receiving treatment such as wound care.

People, healthcare professionals and visitors were complimentary of the staff and the care provided at the home. We saw staff engaged well with people. People looked well presented with clean clothes and hair and people’s privacy and dignity was promoted. Relatives and friends were able to visit the home at any time.

The provider had made improvements which ensured people received the food and fluids they required to maintain their health. Those people assessed as at risk of dehydration or malnutrition were provided with additional support and monitoring to meet their needs. The registered manager, and staff, of the home worked well with the dietician, GP, speech and language team, and other healthcare professionals to support people with their healthcare needs.

Complaints were responded to appropriately. The registered manager ensured all complaints, both formal and informal, were logged centrally to identify any trends or themes and taken action when necessary.

The registered manager understood their responsibilities and the requirements of the Mental Capacity Act and the Deprivation of Liberty Safeguards (permission needs to be sought when a person who does not have capacity has their liberty restricted).

There were improvements in the management of the home. The provider had recruited a new manager and a deputy manager. People, relatives and staff spoke positively about the new managerial team. They had worked hard to improve the standards in the home, recruit new staff, motivate existing staff, and promote an open and transparent culture.

The provider’s regional manager supported the managerial team and staff and was motivated to improve the care given to people living at the home. Staff spoke highly of their support and commitment to improve the service.

Regular quality audits of the home were conducted to monitor and improve the care provided by the service. Analysis of incidents and accidents were carried out to minimise the likelihood of them happening again.

We observed care being provided to people and spoke with two people living at the home. We tried to speak with a number of other people living at Milverton Gate but they were unable to communicate with us. We spoke with seven staff, the manager and the regional director.

We saw the action plan the provider of the service sent to us had been carried out. (this is a document telling us what the service will do to become compliant). This included increasing the number of care hours by 12 hours a day and conducting a review of dependency levels.

The staff we spoke with thought the increase in the number of hours for care work had improved care provided to people. Some staff felt there was still not enough staff in the afternoon to meet people's needs on the first floor.

We spoke with one person at length on the first floor. They told us that they had seen improvements in staffing and their call bell was answered quickly most of the time.

We spoke with the manager and regional manager. They told us they were satisfied that staffing levels now met the needs of people living at Milverton Gate.

We saw staff worked hard to meet the needs of people living at the home. We were concerned there were insufficient staff to meet the complex needs of people living at Milverton Gate.

We looked at three care records. We were satisfied that care records gave sufficient information to ensure that staff treated and supported people appropriately.

We looked at whether the service met the nutritional needs of people. We were satisfied the service provided people with a menu they liked and was responsive to people's individual diets and eating needs.

We checked to ensure staff were clear about procedures to safeguard people living at Milverton Gate. We were satisfied staff had a good understanding of their responsibilities.

We checked the organisation had robust and effective recruitment procedures. We were satisfied recruitment procedures supported the recruitment of staff who were safe and had the necessary skills and experience to undertake their roles.