Archived: Millfield Lodge Care Home Limited

Updated 4 October 2017

We undertook an unannounced focused inspection of Millfield Lodge Care Home Limited on 4 July, 1 and 9 August 2017. This inspection was undertaken to check that improvements, to meet legal requirements planned by the provider after our comprehensive inspection on 12 and 20 April 2017, had been made.

It was also in response to concerns reported to us about the safety of people who lived at the service. We inspected the service against two of the five questions we ask about services: is the service safe? And; is the service well-led?

This focused inspection was undertaken by two inspectors on 4 July 2017 and two inspectors and an inspection manager on 1 and 9 August 2017.

As part of our inspection planning we requested information from those organisations who commission care at the service. We looked at this and other information we hold about the service, which included information from notifications the provider sent to us. A notification is information about important events which the provider is required to send to us by law. We also requested and received details about the provider’s financial viability.

During the inspection we spoke with three people living in the service. We also spoke with the nominated individual. This is the person who has overall responsibility for supervising the management of the regulated activity, and ensuring the quality of the service provided. This was as well as speaking with the deputy manager, two staff from the nursing management agency, a nursing consultant, a nurse, one senior care staff, two care staff and the chef. We also spoke with a visiting pest controller and a member of the fire service.

We observed how people were cared for to help us understand the experience of people who could not talk with us.

We looked at 11 people’s care records, medication administration records and records in relation to the management of the service, including records of accidents and incidents.

Updated 4 October 2017

We carried out this unannounced inspection of Millfield Lodge Care Home Limited on 4 July and 1 and 9 August 2017.

At the previous inspection on 12 and 20 April 2017 the service was rated as ‘Requires Improvement'. We found four breaches of legal requirements. These were in relation to the safeguarding of people, people’s care records, the governance of the service and incidents, such as serious injuries, not being reported to us.

As a result of our concerns we imposed additional conditions on the provider’s registration. We required the service to not admit any more people without our written permission. We also required information to be sent to us on a monthly basis to show us how the service was assessing and monitoring the safety and quality of the service being provided to people.

After this inspection we received further concerns about the service and we undertook this inspection. This report only covers our findings in relation to the concerns reported to us, to those requirements and the enforcement actions we took.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Millfield Lodge Care Home Limited on our website at www.cqc.org.uk.

Millfield Lodge Care Home Limited is registered to provide accommodation and nursing care for up to 31 people. At the time of our inspection there were 16 people living at the service on the 4 July 2017 and 11 people on 1 and 9 August 2017. The service is a single storey premises located on the outskirts of Gamlingay with accessible garden areas. The service has communal lounges and dining areas. All bedrooms are single rooms with an en-suite toilet and washbasin facilities in 27 of these.

A registered manager was not currently in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

The management of the service was being overseen by a nursing management agency. They were assisting with the day to day running of this service. However, on 8 August 2017, they informed us that they were withdrawing their services due to the registered provider not being willing to support the actions needed to make the required improvements. People were not always safely supported with the management, administration and recording of their prescribed medicines. The premises were not safe and actions previously identified and made known to the registered provider had not been acted upon.

Where people had been identified as being at risk, assessments such as those for skin integrity had been completed. However, where these risks had been identified, the registered provider was not supporting people in a safe way or adhering to health care professionals’ advice and guidance. This put people at serious risk of harm.

There were no systems or processes to ensure that the service provided was safe, or well led. The registered provider was unable to demonstrate the skills, knowledge or ability to make the urgent changes that were required to make the service safe.

A sufficient number of staff with the right skills could not be assured to be in place to meet people’s assessed needs. There was not always a nurse on duty to carry out the health care tasks that people needed. This placed people’s health and welfare at serious risk.

Where accidents and incidents had occurred, these had not always been acted upon and reported to the appropriate authorities. Also, the registered provider had repeatedly not responded to the local authority’s request for investigations and information about previous incidents. This meant that the registered provider missed opportunities to identify or learn lessons and this put other people at risk of the same, or similar, risk of harm.

Although people’s care plans had been reviewed, full information about the needs of people were not available to staff. This was because the registered provider had removed information from the service.

Some improvements had been made to the governance arrangements in the service and this had been entirely due to the consultant nursing agency’s input. However, the registered provider’s lack of openness, honesty and candour put people at serious risk of harm.

At this inspection we found serious breaches of Regulations 5, 12, 13, 15, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

These breaches were assessed by CQC as extreme, as the seriousness of the concerns meant that unless we took the action we believed people would/potentially be at risk of harm.

The provider had 28 days to appeal against this decision to the First Tier Tribunal (Care Standards) under section 32 (1) (b) of the Health and Social Care Act 2008. This period has now passed and we can report on the decision that had been ratified by a judge and the action we took.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded. No representations were made.

At this inspection we found there had been further deterioration in the service provision. The overall rating for this provider is 'Inadequate'. On 10 August 2017 CQC used its urgent powers to keep people safe. This means that it can no longer provide any regulated activities and is closed.

Other stakeholders including the local authority supported people and relatives to find other homes or alternative care arrangements. On 10 August 2017, all 11 people using the service were safely moved from this service.

You can see the enforcement action we took at the end of this report.