Archived: Milestone House

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulations in relation to person centred care and consent to care and treatment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. Before people moved to the service their needs were assessed. These assessments were carried out to develop the person’s care plans and make the decisions about the staffing hours and skills needed to support the person. Assessments included making sure that support was planned for people’s diversity needs, such as their, gender and their abilities. However, the assessments were not always clear and detailed to give staff all the information they need to provide care and support. Also, when assessments were updated and amended the changes were not then amended in the person’s care plan which led to inconsistent information. A person’s choking assessment had not ben scored correctly which meant their overall choking risk had been miscalculated. We reviewed this with a member of staff who agreed this incorrect. Bed rails assessments did not show that the type of bed rail had been assessed for the type of bed. We provided information to the manager about bed rails assessments and directed them to the Health and Safety Executive guidance on safe use of bed rails.

Some assessments included information about what people could do for themselves. Each person’s care plan and assessments were also reassessed once a month. Staff confirmed this. Staff were knowledgeable about people’s care and support needs. They were able to describe peoples preferred routines, the best ways to communicate with people and how to support people with their physical and emotional well-being.

Relatives told us they were not involved in their loved one’s assessments and care planning processes. A relative told us they were “Not really involved in planning [loved ones] care and support.” Another relative said, “Have not seen my [loved ones] care plan and not been involved in such.”

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.Care plans and risk assessments clearly described what modified diet people were prescribed and the care plans followed The International Dysphagia Diet Standardisation Initiative (IDDSI) framework. The guidance was also available in the kitchen to staff responsible for preparing, cooking and serving meals. Kitchen staff and those responsible for supporting people with their food had a good understanding of people’s assessed needs in relation to type and texture of food as well as any allergies and food intolerances. However, staff had served food to 4 people on 28 May 2025 which did not meet people’s assessed needs, food had been cut up into too big pieces and it was not at the correct texture.

Staff told us they helped people to make their meal choices if they needed it. We observed staff asking people what food choices they would like. We observed people being given alternative meals when they did not like the meal they had been served. A person said, “I can’t eat that, I don’t like it.” They were offered egg on toast as another option, which the person accepted.

It was not always evident that enough drinks were offered to keep people safe and healthy. Records showed people were not having enough fluids to keep well. We discussed this with the manager. They felt this was a recording issue and added this to the action plan for improvements but needed to investigate this further to make sure. We observed people being prompted and encouraged to drink throughout the day.

People gave us mixed feedback about the food. Comments included, “I love the food, I get to choose. I had baked beans on toast tonight” and “The food is crap, it’s not that good, my favourite is spag bol [spaghetti bolognaise]. I can choose spag bol.”

Care plans showed that some people had goals and aspirations but did not show how and if people had been supported to achieve their goals such as taking holidays. A person told us, “I have not been supported to have a holiday. I would like to go out somewhere.” Another person said, “I have not been [on holiday].”

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services. Staff did not always work with health professionals in a timely manner to ensure people got the care and support they needed. A healthcare professional told us staff picked up on changes to people’s health. They said, “I believe they are very good at this.” However, evidence reviewed during this assessment evidenced health concerns regarding constipation had not always been shared appropriately.

The manager told us they had good links with the GP surgery as well as links with the learning disability community nursing team. Staff told us there were good links with other health professionals such.as occupational therapists. People told us staff worked with GP’s and health professionals to meet their health needs. A person said, “If I am not well, they call the doctor, and he comes here.” Another person said, “I have new glasses, and I am getting a new chair soon.”

Staff worked closely and communicated with day service staff in relation to some people who attended day services as part of their weekly routines.

The provider did not always support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Despite people having health action plans in place, staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. Hospital passports were in place. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital. However, these were not always up to date with people’s needs. For example, a person suffered with constipation and their hospital passport did not mention this. Other records showed that people had seen GP, hospital, dentist, optician when needed.

A relative told us their loved one had not been supported effectively when they needed hospital treatment. They said, “[Loved one] had to go off to hospital at short notice, whilst we were informed via phone, she was sent off to hospital in an ambulance without a care staff member and spent the first approx. one hour with no one with her that she knew.”

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Each person had a DisDAT (Disability Distress Assessment Tool) in place. The DisDAT tool helps identify distress cues in people who have limited communication. It focuses on documenting a person's typical behavioural cues to better recognise subtle changes that may indicate distress. A staff member told us, “I have been here a long time and feel I know the residents. Those that can’t speak we always ask, you can tell by their facial expressions. It’s hard to explain, you get to know for instance they clench their lips which is a no.” A person’s care records showed they were frequently becoming distressed and agitated which resulted in them displaying behaviours which others find challenging. This was directed at staff, generally when having personal care. The person was being supported by the community learning disability nurses in relation to this. There had been some guidance provided to staff, but this had not been incorporated into their care plan and risk assessments. The community learning disability team had reviewed the records of the person’s episodes of distress and had found that records were not always being filled in.

Staff told us they were did not feel listened to or supported by the provider and registered manager in relation to working with the person who was anxious and distressed. A staff member said, “Staff are not being supported; one got punched, the manager does know. They just fill in a form.”

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. We checked whether the service was working within the principles of the Mental Capacity Act (MCA), whether appropriate legal authorisations were in place when needed to deprive a person of their liberty. The service had not always worked within the principles of the MCA and if needed. Appropriate legal authorisations were in place to deprive a person of their liberty (DoLS). A person’s DoLS had a condition in place which had not been met. Staff thought the DoLS condition was for the local authority to meet and were not aware that the condition was for the service.

When people were assessed as lacking capacity to make decisions appropriate procedures were not always followed to ensure principles within the MCA were followed. Decisions made were not always appropriately documented to demonstrate who had been involved in the decision. For example, 1 person’s file showed they were better at making decisions and choices in the mornings, but their capacity assessments had been completed in the afternoon. It was not always clear in the completed assessments if people lacked capacity or not. It was not always documented that other people (such as relatives, GP, advocate) had been involved in best interest decision making. Some people had an RPR (Relevant Person's Representative) who regularly visited them. An RPR is a role designed to support and represent people who are deprived of their liberty under DoLS, ensuring their rights are protected and their views are heard.

People told us they made choices, and we observed people making choices throughout the assessment. Care records showed where people made choices. Some people’s choices had not always been listened to. For example, a person’s records showed they did not want a bath, however they were bathed which caused them anxiety and distress.

Staff described how they offered people choices including what to wear, what to eat and how to spend their time. We observed staff practice. Where people needed additional support to make choices, alternative methods were used to communicate with people. This included visual aids. A staff member said, “We use pictures to help people make food choices. [Person] is non-verbal, and we hold things up and see if we get a reaction. Most of the time it is choosing things for her that is age appropriate and appropriate for the weather.”