2 Millbrook Way

Updated 3 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was completed by one inspector.

Service and service type

2 Millbrook Way is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.

What we did before the inspection

We reviewed information we had received about the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

During the inspection

We spoke with four people living in the home and the relatives of one person. We met with the registered manager, deputy manager and spoke with two staff and received one response to a questionnaire sent to most staff. We contacted commissioners for their views of the service. We walked around the home and gardens.

We reviewed a range of records. This included two peoples full care records and the partial records of a further three people. We looked at the medicine records for five people. We reviewed a variety of safety and maintenance records including fire safety. We looked at a range of quality assurance records, training information, staff rotas and the recruitment records for three people.

Updated 3 August 2022

About the service

2 Millbrook Way provides personal care and accommodation for up to six people with learning disabilities and/or autism. Accommodation is provided in a combination of single person and shared housing. At the time of inspection there were five people living in the home.

People's experience of using this service and what we found

People were not always safe because some of the risks in relation to people's behavioural support needs had not been reviewed and updated regularly. Learning from incidents which included physical intervention and restraint had not been fully recorded or analysed to avoid reoccurrence and improve practice. It was not clear what the procedure was for reporting any concerns about minor injuries received during physical interventions and restraint. We were not assured all staff had received suitable training to support people with physical intervention and restraint.

People were supported by enough staff who had been recruited safely. Staff appeared knowledgeable about the people they supported and worked compassionately with them. One relative told us "I do believe that [name] is fully supported to be safe and secure at Millbrook and also out in the community." And "There is always enough staff on duty to support [name] and there are always familiar faces and staff with the knowledge of the special skills needed to support them at any given time."

People's needs and preferences had been assessed with their involvement, as far as possible, their relatives and other professionals. People's assessments provided enough information to guide staff. A relative told us, "The staff are fully equipped with the knowledge they need and they are learning every day. The new staff are supported by the more experienced staff and they gain knowledge and skills as they progress with the support of the senior staff and management team."

The management oversight of the quality of care records had not identified the issues we found during the inspection in relation to incidents, which included physical intervention and restraint when supporting people experiencing distress.

People were supported by a committed, caring and motivated staff team. Staff we spoke with said they could always ask managers for support and felt they would be listened to and responded to.

Mental Capacity Act

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture

Right support

Staff focused on people’s strengths and promoted what they could do, so people had a fulfilling and meaningful everyday life. Care records included good detail about what was important to the person and how they preferred to be supported.

Right care

People received compassionate and kind support from staff who were motivated to understand their needs and provide person-centred care.

Right culture

Care records and staff interactions we saw demonstrated respect and understanding about the people living in the home. We saw people appearing to be delighted when some staff approached them.

The service was supporting people in ways that considered their ability to be involved in decision making and sought to protect their rights as citizens.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 21 December 2020).

Why we inspected

The inspection was prompted in part due to concerns received about safe care and treatment and staffing. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this focused report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

Enforcement

We have identified breaches in relation to safe care and treatment, safeguarding vulnerable people, staffing and management oversight of incidents, at this inspection. We have also made a recommendation in relation to the protocols for reporting incidents to other professionals.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.