Archived: Milestone House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to risk management, management of accidents and incidents, management of premises and equipment, and staffing.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We could not be assured people benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. Accidents and incidents had not always been reviewed and dealt with by the management team in a timely manner. For example, all the accidents and incidents for the month of May 2025 remained on a file for management action during the site visit on 28 and 29 May 2025. This meant no lessons learnt were explored or shared with staff to prevent similar incidents and accidents occurring. The manager told us they had not reviewed them yet. A staff member said, “We don’t have lessons learned and [the manager] does not discuss.” Another staff member said, “I don’t feel supported after an incident. We have only had one meeting to try and discuss things, but nothing changed.” The registered manager and registered provider had no oversight of accidents and incidents. Not all accidents and incidents had been appropriately logged and reported. We found a body map report for one person which showed bruising to their shoulder. Staff had recorded this may have been due to a fall that had occurred the week before, there was no log or accident/incident record of the fall, and the manager of the service was unaware there had been a fall.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visit, support was in place as well as hospital passports. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital. People’s hospital passports were not always up to date to reflect their currents needs. For example, a person suffered with constipation and their passport did not provide any details about this. The service had referred people to speech and language therapy (SaLT) when required. However, SaLT guidance was not always followed by staff. This put people at risk of harm. Staff did not always feel that people’s safety was effectively monitored. A member of staff told us, “I don’t feel assured that [person] is not having seizures in [their] room, we just have to keep checking. There is no equipment in place to monitor.” The person told us, “Staff keep me safe when I have a seizure.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. The provider had not protected people from avoidable harm as they had failed to maintain the vehicle of the service. The vehicle should have been checked regularly to check the lifting equipment was safe. This had not happened. The winch to the vehicle (to aid wheelchair users to access the vehicle) had snapped whilst being used on 8 May 2025 which has caused the person and a staff member to roll back down the ramp. The manager shared how they had raised a safeguarding alert with the local authority in relation to a person’s finances and evidenced that action had been taken to keep the person safe. A person said, “I feel safe”. Relatives told us their loved ones were safe from harm. A relative told us, “We feel she is safe. We know and trust the staff.”

Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Most people required physical support to move around the service. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing, and most were confident to speak up if needed. A staff member said, “I would report abuse to [manager], it would be dealt with. I could report it to CQC.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people were not always identified and risk assessments lacked enough detailed information for staff to know how to keep people safe. For example, people with epilepsy had no risk assessments in place detailing how staff should safely work with them when supporting them with a seizure, which included risks associated with bathing/showering, sudden unexpected death in epilepsy (SUDEP) and injuries. Risk assessments for people who suffered with constipation were not in place. There was no detail about how often people normally opened their bowels and when to seek medical advice. Staff had not requested medical help to alleviate constipation when it was required for a person.

The provider had inadequate systems in place to manage choking risks. On 28 May 2025 we observed food being given to 4 people which did not meet their individual IDDSI (The International Dysphagia Diet Standardisation Initiative) guidance because the food had been cut up into too big pieces and not at the correct texture. Staff confirmed that was is a regular occurrence. We raised this with the manager and the local authority.

Accident and incident records evidenced that timely and appropriate action had not always been taken to address incidents. We reviewed an accident form dated 8 May 2025 relating to a person. The winch had broken on the vehicle whilst the person was being loaded in the vehicle. This had caused the person to roll back down the slope into the car park. This had put them and staff at serious risk of harm.

The provider had an inadequate system in place in relation to meeting Lifting Operations and Lifting Equipment Regulations (LOLER) regulations to maintain and check lifting equipment. This put people and staff at risk of serious harm. The vehicle had not undergone routine LOLER checks to ensure the lifting equipment (the winch) was safe to use. We raised this at the assessment visit. The manager arranged for an engineer to call on to site and they attended on 23 June 2025. Their report of the visit evidences the lifting equipment had not been checked previously and the equipment was dangerous to use. The report stated that the defects were an existing or imminent danger to persons.

The systems to assess monitor and improve the service were not robust. Registered persons had not identified building related risks in relation to risks of burns from hot surfaces and falls because the door to the boiler and hot water tank room had been left unlocked and unattended on 28 May 2025. On 28 May 2025 we also observed that the door to the cellar which had a keypad lock fitted was on the latch and not locked. Staff we spoke with told us this was not normally locked. This put people at risk of harm, 5 people living at the service were able to walk independently around the service.

The provider had an inadequate system in place to manage fire risks. Weekly tests of the fire alarm system had not always taken place. This meant the provider could not be assured that the fire alarm and fire doors were working as they should be. Personal emergency evacuation plans (PEEPS) were in place which were not always up to date and clear. For example, a person’s PEEP recorded they lived on the first floor, which was not correct. PEEPs did not detail equipment to be used to aid evacuation.

Despite the evidence above relatives told us their loved ones were safe, and staff knew them well. A staff member told us that fire drills did not take place regularly. They told us the manager updated people’s care plans and risk assessments. “Seniors review them monthly.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We observed that risks to people related to the building were not always well managed. Registered persons had not suitably maintained the premises and equipment. Maintenance tasks had not been completed in a timely manner. For example, we observed that the lounge carpet was dirty and stained. A person’s bedroom had flooring which was worn, uneven and had been patched with carpet tiles. These tiles had been badly fitted and had holes and gaps which could cause trip hazards. Another person’s bedroom was missing a window restrictor. There were no records of window restrictor checks taking place. The flush to the staff toilet was missing. The flooring and toilet flush had been identified at the last inspection of the service in 2023. Registered persons had not ensured that the emergency lights within the building had been checked on a monthly basis to ensure they were working. This test is a requirement of UK Fire Safety legislation. Staff told us the provider was not keen to spend money on repairing the service. A staff member told us the vehicle had broken many times, they said it had been, “Bodged when repaired.” Relatives did not provide feedback about the environment of Milestone House. Some relatives lived a long distance away and did not visit that often.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. The registered manager had failed to undertake training to support them in effectively carrying out their role. The training matrix showed they had completed 8 training courses out of 28 training courses. This (coupled with a failure to keep up to date with good practice guidance and gain support from organisations to support improvement) did not assure us of their skills and knowledge to provide support, advice and guidance to the manager and staff as well as skills and knowledge to review care plans and risk assessments to ensure that care plans and risk assessments met training and guidance.

We observed there to be sufficient staff on shift during the site visits to support people’s care and support needs, however staff on shift on some days were having to carry out cooking tasks which takes them away from providing care and support. It was not clear from the rotas how staff had been deployed to meet people’s care and support needs, which included 1:1 hours funded to support them to live a meaningful and fulfilled life. There were only 2 night staff on shift each night. No checks had been carried out to see how 2 staff could support people in an emergency to evacuate at night. There were 4 people at the service who would require 2 staff to assist them in evacuating. We reported our concerns to Kent Fire and Rescue Service. They visited and told the provider to take some actions, this included deploying an extra member of staff on shift at night. This was because fire evacuations could not be achieved in a timely manner. A staff member told us, “There is enough to get done what needs to be done but just that, wash and feed them. We are at ratio and are able to get the residents to their clubs. If we had more staff, we could do more with them.”

Safe recruitment practice had not always been followed. We checked staff recruitment records and found the provider had not picked up anomalies with staff applications and references. For example, a staff member received a reference from an employer which was not even listed on their application as a current or past employer. The provider had retained copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff confirmed they had received an induction before they started work and had received the training and supervision they needed to fulfil their role. Some staff felt they were supported to carry out their roles. A member of staff said, “[The manager] makes sure we are up to date with our training. Some is online and we have just had face to face first aid training. Moving and handling training is once a year. [The manager] does competency checks.” They explained new staff shadowed experienced staff for several weeks to help them get to know people and their wants and needs. Other comments were, “I have been supported when I need it but not everyone does” and “I feel supported, we have supervisions.” The manager had only had 1 supervision in the time they had been employed. The registered manager confirmed this was in January 2025.

Relatives told us there were enough staff on duty when they visited. They all said that staff knew their loved ones well. A relative said, “When I go down in the afternoon, they always have a member of staff in the lounge.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The provider had not taken action to address the infection control risks that had been highlighted in the infection control audits undertaken by the manager. The service was not clean in some areas. Gaps in flooring in a person’s bedroom created infection control risks as the floor could not effectively be kept clean. The lounge carpet was dirty and stained and the flush being broken also created an infection risk. A housekeeper was employed; on the days the housekeeper did not work care staff carried out basic cleaning. Staff were trained in preventing and controlling the spread of infection. The manager completed regular infection control audits to check the service. We observed staff using personal protective equipment appropriately (PPE). A staff member said, “There is always plenty of PPE.” Relatives told us the home was clean and tidy. Comments included, “The home is always clean as is [loved one’s] room and has no bad smell as such” and “When we visit it is clean and fresh.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The provider had systems and processes in place to manage medicines. Medicines care plans were detailed and person-centred. They provided good information to support staff to understand people's care needs and linked to care planning for specific conditions. The ordering process for prescribed medicine was effective, and we were able to reconcile medicines stock with prescribing. The management team carried out regular medicine audits. People received their medicines from trained staff. The staff informed us they received training and were competency assessed to handle medicines safely. People were supported by the local GP and had regular medicines reviews in line with STOMP (Stopping over medication of people with a learning disability and autistic people.) People received as and when required medicines when they needed it.

People received their medicines safely. A relative told us, “She gets her medication when required.” A person told us, “Staff do my medicines, and they give me paracetamol.” We observed the staff were polite, gained consent, and recorded the administration of medicines on the medicines administration record (MAR).