We carried out a review of the data available to us about Radis Community Care (Millbrook House) on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Radis Community Care (Millbrook House), you can give feedback on this service.
Radis Community Care (Millbrook House) provides personal care to people living in ‘extra care’ housing.
People’s experience of using this service and what we found
People felt safe and were protected as far as possible by staff who were competent to recognise and report any avoidable harm or abuse. Potential risks to people had been assessed and measures put in place to minimise the risks.
There were enough staff to make sure people were safe, and their needs met in a timely manner. Pre-employment checks were completed on staff before they were assessed to be suitable to look after people who used the service. Staff understood their responsibility to report any accidents and incidents. These were analysed by the registered manager on a monthly basis to identify if there were any themes.
People were supported to take their medicines by staff who were trained and had been assessed to be competent to administer medicines.
Staff received induction, training and support including supervision and appraisals to enable them to do their job well.
Assessments of people’s needs were carried out to ensure that the service could meet their needs in the way the person preferred. Technology such as an alarm call system was used via the wearing of pendants for every person using the service to enhance the care being provided.
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.
Staff respected people’s privacy and dignity and supported people to remain as independent as possible. People made positive comments about the staff. One person said, “The staff are wonderful and so caring.” Staff treated people kindly. Staff were knowledgeable about each person and knew their likes and dislikes. People were involved in planning their care and support.
Care plans gave staff detailed guidance relating to the care and support each person needed so that people received personalised care that was responsive to their needs.
A complaints process was in place and a complaint received had been dealt with in a timely manner. The provider had a policy and procedure in place to meet people’s end-of-life care needs when this was required.
Staff felt supported by the registered manager. Staff were clear about their role to provide people with a high-quality service. Staff enjoyed working for at the service. One member of staff said, “It’s great here and we all get on really well as a team.”
A quality assurance system was in place which included an annual questionnaire to enable people, relatives and other interested parties to have a say about how the service was run and how to make any improvements. Audits and monitoring checks on various aspects of the service, including spot-checks on the way staff worked with people were carried out.
The registered manager was aware of the various matters that the service was required by law to notify CQC about. Staff worked in partnership with other professionals to ensure that joined-up care was provided to people.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection:
At the last inspection we rated this service Good (report published on 31 December 2016).
Why we inspected:
This was a planned inspection based on the previous rating.
Follow up:
We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we might inspect sooner.
Our last inspection took place on 21 and 24 September 2015 and as a result of our findings we asked the provider to make improvements to medicines management, the application of the Mental Capacity Act 2005, and monitoring the quality of the service provision. We received an action plan detailing how and when the required improvements would be made by.
This unannounced inspection took place on 14 November 2016. There were 17 people receiving care at that time. We found that sufficient improvements had been made in regard to all areas.
The service had a registered manager in place. 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.
There were systems in place to ensure the ongoing suitability of staff to work with people who used the service. Staff were trained to meet the needs of the people they provided a service to. They were well supported by their managers. There were sufficient staff to meet people’s assessed needs.
Systems were in place to ensure people’s safety was effectively managed. Staff were aware of the procedures for reporting concerns and of how to protect people from harm. People were supported to manage their prescribed medicines safely. People’s health, care and support needs were effectively met and monitored.
People’s rights to make decisions about their care were respected. Where people did not have the mental capacity to make decisions, they had been supported in the decision making process.
People received care and support from staff who were kind, caring, pleasant and respectful to the people they were caring for. Staff treated people with dignity and respect. People were involved in the writing and reviewing of their care plans.
Care records were detailed and provided staff with sufficient guidance to provide consistent care to each person. Changes to people’s care was kept under review to ensure the change was effective.
The registered manager was supported by a staff team that included team leaders and care workers. The service was well run and staff, including the registered manager, were approachable. People and relatives were encouraged to provide feedback on the service in various ways both formally and informally. There were systems in place to monitor the quality of the service. When areas for improvement were identified action was taken to address the shortfalls.
Radis Community Care (Millbrook House) is registered to provide personal care to people living in their own homes. During this inspection personal care was provided to 22 people, all of whom lived within Millbrook House.
The service had a registered manager in place. 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.
Our last inspection took place on 19 and 26 August 2014 and as a result of our findings we asked the provider to make improvements to staff knowledge and application of the Mental Capacity Act 2005, care planning and risk assessment, the management of medicines and assessing and monitoring the quality of the service provision. We received an action plan detailing how and when the required improvements would be made by.
This announced inspection took place on 21 September 2015. We found that sufficient improvements had been made to ensure people care was effectively planned and risks managed. Although improvements had been made in the other areas, there were shortfalls in the management of medicines, the application of the Mental Capacity Act 2005 and the governance of the service. You can see what action we told the provider to take at the back of the full version of the report.
People were not always supported to manage their prescribed medicines safely. Systems were in place to ensure people’s safety was effectively managed. Staff were aware of the procedures for reporting concerns and of how to protect people from harm.
Staff were only employed after the provider carried out satisfactory pre-employment checks. Staff were trained and well supported by their managers. There were sufficient staff to meet people’s assessed needs.
The CQC monitors the operations of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. People’s decisions were respected. However, where people did not have the mental capacity to make decisions, processes had not been followed to protect people from unlawful restriction and unlawful decision making.
People’s health and care needs were effectively met.
People received care and support from staff who were kind, friendly, caring and respectful.
Staff respected people’s privacy and dignity. People were encouraged to express their views on the service provided and the care planning process. People’s care records were detailed and provided staff with sufficient guidance to provide consistent care to each person. Changes to people’s care needs was kept under review to ensure any changes to the care provided was effective.
The registered manager managed three other services in addition to this one. The registered manager was supported by a team leader and care workers. People felt listened to and the registered manager used their feedback, together with audits of the service to drive improvement. However, the provider’s quality assurance system was not always effective and did not effectively assess and monitor the quality of the service.
We found three breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
' Is the service safe?
' Is the service effective?
' Is the service caring?
' Is the service responsive?
' Is the service well led?
Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at. If you would like to see the evidence that supports the summary, please read the full report.
During our inspection we spoke with three people who received a service, and four staff members. The registered manager was on leave at the time of our inspection, but another manager from the provider's organisation was present. We also received further information from the provider on 26 August 2014.
Is the service safe?
People told us that they felt safe with the staff who provided their care. Staff had undertaken training relating to safeguarding vulnerable adults from abuse. They demonstrated that they would report any concerns appropriately.
When we reviewed people's care records we found that that although they all contained risk assessments, some areas of risk had not been identified or assessed by the provider. This meant there was a risk that people were not safe because risks might not have been identified.
Is the service effective?
We spoke with three people who received care from this service. They were all complimentary about the care they received and said that it met their needs. One person told us, 'Staff listen to me and do things exactly as I want.' Another person told us, 'I'd be lost without them.'
Is the service caring?
People told us that the staff providing the service to them were caring. One person said that the staff were 'very good, absolutely perfect. I can't say anything against them. If I want help, they are there.' People told us that staff did ask them about the care they needed. They said staff listened to them and acted on their preferences.
Is the service responsive?
People that we spoke with told us that their requests had been accommodated where they had requested changes to the time, or the way, their care was provided. However, because people's needs and the care provided to them were not regularly reviewed there was a risk that the provider would not respond appropriately to people's changing needs.
Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. However, where people did not have the capacity to consent, the provider had not checked they were acting in accordance with legal requirements before providing care.
Is the service well-led?
People receiving a service told us that staff regularly checked that they were satisfied with the service provided to them. Senior staff told us that this was an informal process and no records were kept or analysis made. In addition, we found that there was no evidence of analysis of complaints received or incidents that occurred.
Care workers told us they felt supported by senior staff and had received training in relevant topics. However, we found that checks of night staff and team leaders' work had not taken place.
Although the provider had quality assurance policies in place, which included the use of various audits, these were not being followed. We found little information had been gathered in relation to the standard of the service provided since the provider registered in November 2013. We noted that a quality audit had been conducted by the provider's representative on 30 July 2014 and that the team leaders had taken notes of, and were addressing, some of the areas for improvement. However, at the time of the inspection on 19 August 2014, the staff at the service had not received a copy of the report. We were provided with a copy of the report a week after our inspection. This showed that there were 19 areas for improvement documented.
A registered manager was in post at the service. However, we noted that they spent less than one day each week at the service because they managed three other, similar, services.
We found that the provider was not compliant with the regulations in four of the six areas we assessed. We have asked the provider to tell us how they will make improvements and meet the requirements of the law. If you wish to see the evidence supporting our summary please read the full report.