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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in continued breach of legal regulations in relation to safe care and treatment, management of premises and equipment and staffing. Two new breaches were identified in relation to safeguarding people from abuse and recruitment.

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 continued to 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, we observed a person with bruising and cuts to their arm. A staff member told us they thought the person had caused the injuries by scratching. We checked to see if incident or accident reports or body maps had been completed, we were unable to find any and these were not located by the staff or manager. The last body map found in relation to the person was dated 15 September 2025 which was an unrelated cut to their finger. The manager and a staff member told us if the body maps and incident forms had not been found, they had not been completed. This meant that appropriate action had not been taken. Another person’s records showed unwitnessed injuries (bruising) on 2 different occasions in September 2025. Whilst the bruises were recorded, investigations had not taken place, and safeguarding concerns had not been raised.

The provider continued to 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. However, these were not always up to date or reflective of their currents needs. For example, a person suffered with constipation and their passport did not provide any details about this. The manager was in the process of reviewing care plans and uploading them on to an electronic system. There had been no new admissions to the service since the last assessment.

At the last assessment we reported that staff did not always feel that people’s safety was effectively monitored. There is no monitoring equipment in place to support a person who had frequent seizures. At this assessment, the manager told us the person was not having as many seizures, their epilepsy appeared to be well managed by the medicines. The person wore a helmet to protect them from injury. The manager told us that the person was encouraged to walk around the service. At the time of the assessment the provider and manager were still researching an epilepsy detector watch which links to a phone. At the time of the feedback meeting with the manager and provider, they told us the watch had been ordered, and they were waiting for delivery. The manager explained this would give the person greater independence and privacy.

The provider continued to 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. We found records of unexplained bruises on people which the provider had not recognised as possible safeguarding concerns, these had not been reported. A person had suffered a burn whilst having a seizure, this had been reported to the local authority as a safeguarding concern but had not been reported to CQC.

The provider has updated their safeguarding policy, and this was accessible to staff. However, the safeguarding policy provided factually inaccurate information about reporting safeguarding, it provided information for staff to report safeguarding concerns to Dover District Council (DDC). Kent County Council is the correct local authority responsible for safeguarding people from abuse.

Most staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff told us, “I did safeguarding. I do think [manager] would deal with it (reports of abuse) if I reported it” and “I have completed all the online training. I would go to a senior and would take it further. If they didn’t do anything I would go further or the owner, but I think the CQC would be my first bet.”

We observed interactions between staff and people during our visit; people were supported to maintain their safety whilst maintaining their routines. People who could mobilise independently were able to move around the service as they wanted. Most people required physical support to move around the service. Relatives told us their loved ones were safe from harm. A relative told us, “I do feel she is safe we haven’t seen or heard anything to the contrary.” Another relative said, “Walking round talking to staff there were issues previously and they have talked about positive change. For example, there is now a sign in for visitors which wasn’t there before.”

The provider continued to 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 2 people.

Accident and incident records evidenced that timely and appropriate action had not always been taken to address incidents.

The provider had made some improvements to their fire systems, and a new fire alarm was in place. The fire risk assessment was still not sufficient to mitigate fire risks, and the fire service had visited on 19 February 2026 to advise that further improvements were required. 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. Fire drills were not always effective to aid staff learning in relation to safe evacuation, to enable staff to safely support people without putting themselves and people at risk of injury. A fire drill took place whilst we were at the service. A staff member hurt their back trying to evacuate a person who did not wish to leave the building. We observed that the muster point in the car park did not have any seating. A person who was evacuated who used a walking frame and was visibly struggling to maintain their balance had to stand for a period of time before being let back into the building. Personal emergency evacuation plans (PEEPS) were in place which were not always up to date and clear. For example, PEEPS did not specify if people required staff to stay with them once they had been evacuated and PEEPs did not provide details of who was prescribed flammable creams which could put them at higher risk in the event of a fire.

Despite the evidence above relatives told us their loved ones were safe, and staff knew them well and they had seen some improvement. A staff member told us that fire drills did not always take place regularly. They said, “I have not done a fire drill since the new alarm was put in, I did one with [previous manager] before the changes.”

The provider continued to 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 were ongoing. We observed items left in a spare ground floor bedroom which could cause harm, such as tools. The room had not been locked to keep people safe. The provider has set out weekly checks for the maintenance person to carry out. We found these essential checks had not been undertaken weekly. The manager told us the maintenance person was not scheduled to be at the service weekly. Registered persons had not ensured that the emergency lights within the building had been checked monthly to ensure they were working. This test is a requirement of UK Fire Safety legislation.

We observed that the provider had made some changes to the environment. New flooring had been laid in the lounge and hallway, this made the flooring easier to clean and reduced the trip hazards. A person told us, “The new floor is nice.” Some people’s bedrooms still had old flooring and carpet tiles with some gaps which had not yet been replaced. Window restrictors had been replaced and checks on window restrictors took place regularly. The flush in the staff toilet was repaired. Relatives told us there had been some improvements to the décor of the service.

Staff told us, “There has been some improvements, they have done the flooring, which looks nice”, “[Person’s] room has changed, we have an overhead hoist in there it is much better, [person] seems much more settled in there and the room gets more light. There were trees outside [person’s] old room which affected the light” and “The flooring has been done, we need to progress more, he needs to sell all the old cars out the front and make an effort to get them off the driveway.”

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.

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 took them away from providing care and support. Staff told us that this impacted people greatly. Staff said, “It impacts on service users as activities can’t happen, it doesn’t impact on care needs as personal care is completed before and after. It is not fair on the service users or staff” and “Some days we are short staffed so people might not get a bath, but they would have a wash. Being short staffed is not a good thing, it makes staffing even more short when we have to cover the kitchen. It impacts on people as staff are taken off care and put in the kitchen, this leaves just 3 care staff on the floor.”

It was not clear from the rotas how staff had been deployed to meet people’s care and support needs, which included any 1:1 support they needed to enable them to live a meaningful and fulfilled life. Staffing at night had increased due to the fire service telling them they were concerned about numbers of staff to carry out safe evacuation in a timely manner. Staff told us that there had been occasions where they had worked day and night shifts back-to-back due to staff shortages. This meant they had not always deployed in a safe manner as they had not been given adequate breaks between shifts, which put them and people at risk

Safe recruitment practice had not been followed. We checked staff recruitment records and found the provider had not picked up anomalies with staff applications and references. For example, there were gaps in employment that had not been explained, dates of employment on application forms did not match references. References had not been verified, and identification documents were missing. The record of Disclosure and Barring Service checks (DBS) were missing. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The training records for the service were incomplete; we asked multiple times during the assessment for the up-to-date training records for all staff. Training did not include all staff on the rota. After the assessment period had ended, we received a copy of the training records which included additional staff and the manager. The rota for the service showed there were 21 staff listed. Only 2 staff had completed autism training, 16 staff had completed behaviours that challenge training, 14 had completed dementia, 16 had completed dysphagia, 15 had completed epilepsy and 2 had completed falls awareness. Only 9 staff had completed first aid and fire safety, 2 staff managing continence and 10 staff had completed moving and handling training. Staff provided support for people with learning disabilities, autism, behaviours that others might find challenging, dementia, epilepsy and people assessed at risk of choking. Staff had not all completed mandatory training to meet people’s needs.

Staff confirmed they had received an induction when they started work and this included shadowing experienced staff to get to know people and their routines. Staff felt they were supported to carry out their roles. Staff said, “The training is good and I always feel l can ask questions if there is anything I have forgotten” and “I last received one (supervision) last year before the new manager started. No, they do not do competency checks not that I can remember” and “The manual handling was really good, and I have learnt things I have never in 4 years which was good. I was not allowed to be on my own until I did moving and handling. You are not allowed to work without completing the training. I think they are extra safe.”

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, “The day we were there we thought there is enough.”

The provider assessed and managed the risk of infection. They detected and controlled therisk of it spreading and shared concerns with appropriate agencies promptly. However, staff were not following safe hand hygiene between people when administering medicines, they were not wearing gloves or washing their hands in between administering each person’s medicine. We observed the service was mainly clean and smelled fresh. A housekeeper carried out cleaning tasks when we were onsite. On the days the housekeeper did not work care staff carried out basic cleaning. Most 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). Staff said, “We have always got PPE provided”, “There is lots of PPE stations everywhere. They go round every day and fill it up” and “We have PPE enough to use.”

Relatives told us the home was clean and tidy. A relative said, “It has improved lately. I used to notice her toilet was always dirty, but it wasn’t this time.”

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 processes were not always robust; people had not always received as and when required medicines (PRN) when they needed it. PRN protocols were not always followed when people were constipated which increased the risk of harm to people.

Medicines administration records (MAR) were in place and staff signed these to evidence they had administered prescribed medicines. Where MARs were handwritten, they were not always double signed to show they’d be verified as correct in line with good practice guidance.

Medicines were stored safely and securely, the medicines room was clean and organised. Appropriate procedures were being followed for medicine disposal. MARs records were complete and audited and totals in stock matched records. There was a system in place to monitor temperatures and plans in place to act if needed. Relatives told us people received their medicines when they needed them.