Milverton Nursing Home

Milverton Nursing Home is a care home providing personal and nursing care to 28 people at the time of the inspection. The service can support up to 30 people.

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

The home was not as well run as it could be. A manager was in place but they were not registered with the CQC. Audit systems were not always effective in identifying areas of improvement and corrective actions taken. The provider assured us they took our feedback on board, however time was needed to ensure these processes were embedded.

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.

People received a safe service, with enough staff to meet their needs. Potential risks to people were assessed and people received their medicines safely. Staff had access to personal protective equipment (PPE).

People, relatives and staff were positive about the management team. The provider worked alongside other agencies to support people’s care needs.

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 14 January 2021).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Recommendations

We have made recommendations in relation to recruitment processes and the duty of candour.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

People and their relatives were happy with the infection prevention and control practices at the home. The provider and manager and members of the management team shared information with people about the service. There were effective systems in place to assess and monitor the quality of the service.

Staff had received training on the use of PPE, social distancing, exposure to COVID-19 and hygiene routines. Staff followed the latest national and local guidance to minimise the spread of infection. Infection prevention schedules and audits were regularly completed to ensure high standards of care.

The provider worked closely with the commissioning authorities to train staff about the current practice of COVID-19 guidance to ensure good practice and to make improvements where needed.

We were assured people were not at risk of harm from the concerns raised about the unsafe following of the COVID-19 guidance at the service.

Rating at last inspection

The last rating for this service was good (published 17 December 2019).

Why we inspected

We undertook this inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in response to concerns received about poor infection prevention and control practices, including staff not using PPE in line with national and local guidance and the manager not ensuring staff practised social distancing and isolation of people who tested positive of the COVID-19. A decision was made for us to inspect and examine those risks.

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.

We found no evidence during this inspection that people were at risk of harm from this concern.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Milverton Nursing Home on our website at www.cqc.org.uk.

The Care Quality Commission (CQC) have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement:

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We found the following examples of good practice:

¿ No visitors were being admitted to the home. The service had set up covered seating areas in the garden. Visitors were required to book in advance to make sure that their visits were spread out to avoid the potential risk of transmission to other visitors and to allow the staff team to clean and sanitise each visiting area between appointments. An internal conservatory area was also being prepared for visits on colder days that could be accessed directly from the garden.

¿ When visitors came to the home, a member of staff supported them to make sure they followed safe infection control and Personal Protective Equipment (PPE) guidance. A short written questionnaire was used to check to check any exposure to, or symptoms of, coronavirus. The staff member then used a forehead thermometer to check the visitor’s temperature.

¿ The home was observed to be clean and free of malodour. Additional hours were allocated for cleaning staff and an external decontamination company had been contracted for regular visits.

¿ Where people were in isolation, barrier nursing procedures were implemented. Allocated staff with their own PPE and equipment supported the person using the service.

¿ All people being admitted to the home were tested prior to admission. People were then asked to self-isolate in their bedrooms for 14 days supported by care staff. The home was taking part in the ‘whole home’ testing programme. This meant that people living in the home were being tested for coronavirus on a monthly basis and staff were being tested weekly. Antibody testing for staff had also just commenced at the time of our inspection.

¿ The service had appropriate infection control policies and procedures in place. They had kept up to date with current government guidance and communicated changes to staff promptly.

¿ Individual risk assessments had been conducted on people and staff which identified any vulnerabilities in relation to coronavirus and any mitigating action that the provider needed to implement. Staff wellbeing was monitored through surveys and management supervision.

Milverton Nursing Home is a residential care home providing personal and nursing care for up to 30 older people, some of whom had dementia. At the time of the inspection 27 people were receiving a service at the home.

Milverton is a large domestic style house in a residential area, with accommodation on three floors. Many but not all bedrooms were en-suite, there were separate bath and shower rooms. There was a large lounge/dining area which led to a new bright and airy sun room and extensive gardens. All areas were accessible by lift or stairs.

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

Risks to people had been assessed and regularly reviewed. People were protected from avoidable harm, discrimination and abuse. Appropriate staff recruitment checks were made. Procedures were in place to reduce the risk of the spread of infection. Medicines were administered and stored safely. The provider kept records of any incidents and accidents that occurred, and took appropriate steps to mitigate the risk of further accidents.

Staff were suitably trained and supported. 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. People were supported to maintain a healthy balanced diet and to stay healthy, with access to health care services as and when required.

People received support from staff who were kind and compassionate. Staff treated people with dignity and respect and ensured people's privacy was always maintained. People were supported to do as much as they could and wanted to do for themselves to retain control and independence over their lives.

People’s communication needs were met. The provider had effective systems in place to deal with concerns and complaints and to assess and monitor the quality of the service people received. People were supported to receive the end of life support that met their needs and was of their choice.

The home was very well run with a positive and visible management team, led by a hands-on registered manager.

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 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Milverton Nursing Home on our website at www.cqc.org.uk.

Milverton Nursing Home provides nursing care for up to 30 older people, some of whom were living with dementia. There were 28 people using the service at the time of our inspection.

There was a registered manager in post. 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 findings showed that the provider managed risks to people using the service and those relating to the premises well. However, risks relating to bed rails were not always well managed as some risks had not been appropriately risk assessed and mitigated. The registered manager told us they would take immediate action regarding these risks.

The registered manager had improved processes for recording incidents since our last inspection to ensure action in response to incidents was appropriate. In addition the registered manager had improved the complaints process to ensure all complaints were recorded and reviewed as part of improving the service.

The activities available to people had been extended since our last inspection to consider the needs of people who spent much time in their rooms to reduce the risks of social isolation. The activities officer organised activities based on people’s interests. These included weekly outings, entertainers and group activities.

A programme of renovations to extend and improve the home was in place and included provision of a new conservatory and staff facilities.

The provider managed people’s medicines safely as staff followed robust procedures in all aspects of medicines management.

Staff understood how to safeguard people at the service and had received training in this area. Staff knew the signs people may be being abused and the registered manager responded to concerns appropriately to keep people safe.

There were enough staff deployed to meet people’s needs. The provider carried out appropriate checks to ensure only staff who were suitable worked with people. These checks included previous work experience and qualifications, including PINs for nurses, identification, right to work in UK and health conditions. A programme of induction, supervision, appraisal and training was in place to help staff understand how to respond to people’s needs. Staff felt supported by the registered manager.

Staff supported people with their healthcare needs including accessing healthcare professionals. Staff knew the people they supported. People’s care plans contained sufficient detail about their support needs, backgrounds and preferences for staff to follow in providing care to them.

People were involved in decisions about their care and staff understood the importance of the Mental Capacity Act 2005 to their role, such as how to respond when people lacked capacity to consent to their care. The registered manager applied for authorisations to deprive people of their liberty appropriately under Deprivation of Liberty Safeguards (DoLS). DoLS provides a process to make sure that people are only deprived of their liberty in a safe and correct way, when it is in their best interests and there is no other way to look after them.

People were provided with a choice of food and were positive about the food they received. The chef ensured food was prepared in accordance with people’s specific dietary and health related needs.

People, relatives and staff told us the service was well-led and the registered manager regularly gathered and acted on their feedback about the service. The registered manager and staff, were aware of their role and responsibilities. The provider carried out a range of quality checks to monitor, assess and improve the quality of service.

Milverton nursing home provides accommodation, personal and nursing care for up to 30 older people, some of whom have dementia. At the time of our inspection 27 people were using the service.

The service had a registered manager in post. 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.

Some aspects of the service required improvement. We saw that processes for recording incidents were not sufficiently robust. The incident reports did not capture the action taken to support the person at the time of the incident, and the response to the incident. Therefore the provider could not demonstrate they were learning from these and taking action to protect people from similar incidents recurring. The complaints process did not capture all complaints, and there was a risk that these concerns would not be learnt from.

A range of activities were provided at the service and there were opportunities to access the local community to stimulate people using the service and protect them from social isolation. People’s views were gathered about what activities they would like delivered at the service. However, there was little opportunity for people who preferred to spend time in their room or did not want to engage in group activities to have one to one activities, and there was a risk that these people may become socially isolated.

People received the support they required with their personal care and health needs. Each person had a care plan which detailed what support they required and how that support should be delivered. The care plans also referred to risk management plans and preventative measures in place to reduce the risks to people’s health and safety.

Staff were knowledgeable about the people they supported. This included being aware of their preferences, their interests and their life experiences. Staff used this information to provide people with the support they required and to build meaningful relationships with people.

People were involved in decisions about their care and the support they received. They were able to choose how they spent their time and were involved in decisions about daily life. Staff were aware of who was able to make decisions and who did not have the capacity to make complex decisions about their care. Where people did not have the capacity to consent to their care, staff adhered to the Mental Capacity Act 2005 and ‘best interests’ decisions were made on people’s behalf.

People received their medicines as prescribed and there were sufficient stocks of medicines at the service. Staff supported people to access healthcare professionals and ensure their health needs were addressed. Staff were knowledgeable about people’s dietary requirements and people who required support at mealtimes received it.

There were sufficient staff on duty to meet people’s needs. We observed staff being attentive to people and responding to requests for support promptly. Staff received the training and supervision they required to have the knowledge and skills to meet people’s needs. Staff received refresher training to ensure they stayed up to date with good practice. Staff worked with other healthcare professionals to further develop their skills, particularly in regards to end of life care.

There was visible leadership and management at the service. Staff, people and relatives felt comfortable speaking with the management team and felt able to express their views and opinions. There were processes in place to obtain people and relatives feedback. Systems were also in place to review the quality of service delivery, and where improvements were identified these were addressed promptly.

If you want to see the evidence supporting our summary please read the full report.

We considered our inspection findings to answer five questions we always ask:

' Is the service safe?

' Is the service caring?

' Is the service responsive?

' Is the service effective?

' Is the service well led?

Is the service safe?

Parts of the service were not safe. Equipment such as pressure relieving mattresses and cushions were not always available to people who required them. Air mattresses were not always used correctly, at the right setting, to provide effective pressure relief. Bed rails were not always used effectively to reduce the risk of people falling out of bed. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to equipment.

Standards of cleanliness and infection control in the kitchen were not sufficient to prevent people from acquiring food-borne infections. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to cleanliness and infection control.

Staff recruitment procedures were not robust as gaps in employment records were not always explored, and the home did not appropriately assess whether people were suitable to work in the home in terms of their physical and mental health. There were enough suitably competent staff on duty to meet the needs of the people who lived at Milverton Nursing Home. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to requirements relating to workers.

The home and gardens were adequately maintained.

Is the service effective?

The service was not always effective. The care provided to people did not always ensure their welfare and safety in relation to wound management and protecting them against the risk of malnutrition. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to care and welfare.

People were provided with a choice of suitable and nutritious food and were supported to eat when necessary.

Is the service caring?

Parts of the service were caring. Staff were not rushed and spent time talking and interacting with people. However, staff did not always treat people with respect when entering their rooms.

Is the service responsive?

The service was not always responsive. Mental capacity assessments were not always carried out appropriately. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to consent.

The service had proper policies and procedures in relation to the Deprivation of Liberty Safeguards (DoLS) and the manager had made several applications, which meant that people were not being deprived of their liberty inappropriately.

Is the service well-led?

The service was not well-led in all areas. Systems were not in place to effectively assess and monitor the quality of the care, issues relating to respect and consent, equipment, cleanliness and recruitment at Milverton Nursing Home. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to assessing and monitoring the quality of service provision. However, systems were in place to monitor health and safety. Also, the home regularly sought the views of people using the service.

"The physical care is good. The home is warm and welcoming. However, emotional care is very patchy and some staff appear to be lacking in empathy and are sometimes reluctant to engage with residents who are in distress. There is also an issue with staff's lack of knowledge and their English is sometimes hard to understand for people".

People who used the service and their relatives told us they were involved in choosing the type of care and support they needed and when they needed it. We were told "We visited and had a look around before our relative moved in". People told us their opinions were sought and generally acted upon regarding the care and support they received and activities they wished to pursue. "My mother has received very good treatment. The staff are very kind and compassionate and are well trained and respectful. I am very happy that my mother is well looked after and always looks clean and content". We saw that the service provided was of good quality regarding people's health and cleanliness needs.

The records and care practices we saw showed us that peoples' preferences, choices and wishes were recorded and where possible met to an extent although not in a particularly person centred way. The activities provided were focused on a group rather than individual environment and therefore people's individual preferences tended to defer to the group activity taking place. The home acknowledged this and we were told that they were developing a more person centred approach to the way they delivered the service .

We saw that people using the service received the care and support they needed to sustain a healthy and reasonable quality of life in a safe and comfortable environment, although work was required to provide more person centred, individual care. A relative we spoke with said "The home provides safe and good quality care. However the majority of the residents have varying degrees of dementia and although they are treated with respect and kindness, I feel that the staff and carers do not have enough time to spend chatting to residents for any length of time because of their many duties. I feel more interaction is needed as it is a long day when living in a home".

We saw that the home endeavoured to work with other providers to deliver a cohesive and joined up service, by providing relevant information in a timely way.

People we spoke with were complimentary about the care and facilities at the home. One person told us that the meals should be given "10 out of 10" and another told us that the food was very good. People also commented positively about the attitude of staff. One person told us that the home had "some staff who cared more than others" and explained this by saying that some staff seem to be more involved than others.

At the time of the inspection we found that there was a mix of care staff, nursing staff, domestic and catering staff. The home was clean and decorated for the Christmas season and most people were up and dressed appropriately for the day. Some people were receiving visitors and others were seated in the lounge.

We found that the meals provided to people allowed for a balanced and nutritional diet and provided the opportunity of choice. We found that people's care needs were being adequately met by staff who interacted with people in a polite and respectful manner.