Millreed Lodge Care Home

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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always recognise, and report concerns about safety. Lessons were not always learnt to continually identify and embed good practice.

There was a lack of consistency in learning lessons from incidents that put people at risk.

When incidents had occurred, this was discussed in staff meetings and ‘Read and sign’ documents were put in place to inform staff of what had happened and what learning they needed to take from them to avoid recurrence. Whilst we saw some evidence of this approach being effective in changing staff practice following 1 incident, staff had failed to recognise and report a situation where a person could have been at risk.

Accident forms were completed but did not include information about actions taken or lessons learnt to reduce the risk of a repeat of the incident.

The provider demonstrated a proactive response in taking learning from some of our feedback during the assessment.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems were not always in place to make sure people’s admissions to the service were safe and provided continuity of care. One person who had been living at the service for 3 days did not have any care records in place. Staff had not reported being unable to see their care plans or input records of care intervention on the electronic care record system. Managers took immediate action to address and report this and to prevent the situation from happening again.

The deputy manager had recognised that documents known as health passports, which were in place for providing important information for medical staff when people needed to access hospital services, were lacking in personalised information. They told us they were working on these to promote continuity of care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

Safeguarding training was provided for staff, and this was completed online. Although care staff were able to tell us about their responsibilities in relation to safeguarding, none had recognised or reported the issue of a person not having any care records as a safeguarding issue. The management team did make a safeguarding referral in relation to this after we discussed it with them.

People and their relatives told us they felt safe because of the attention they received from staff.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In [care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. One person had a DoLS in place and this was managed appropriately.

The Mental Capacity Act 2005 (MCA) outlines how decisions should be made for individuals lacking capacity. However, MCA principles were not consistently followed. Capacity assessments were not always completed, and staff had not always followed the correct procedures in relation to making best interest decisions, which meant people were being placed at possible risk. These concerns were highlighted with the management team who addressed the issue during the course of the assessment.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were in place but varied in quality and it was not clear staff had always followed the actions detailed in the assessment to reduce the risk to the person. For example, 1 person’s risk assessment detailed how they needed to be protected from skin damage when using the hoist. However, we found the safeguards, as detailed in the person’s risk assessment, were not in place.

Where people had been identified as at risk nutritionally or with the health of their skin, there was no clear overview of records relating to nutritional intake or repositioning and we saw repositioning charts did not always reflect that care had been provided in line with the needs identified in people’s care plans and risk assessments. Whilst we did not see any evidence of people having experienced any harm because of this, we sought assurances from the management team that actions to address this would be prioritised which they confirmed.

There was no evidence of people or, where appropriate, their relatives having been involved in the risk assessment process. The management team assured us this would be addressed as part of the transfer of care records to a new electronic care record system.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

On the second day of our assessment, we saw a small note on a bedroom door telling people not to enter as there was a hole in the floor. The note was not sufficient to deter people living with dementia or with poor vision. The door to the room did not have any mechanism to lock or even close it and on entry we saw a large number of tools on the floor and a large hole in the floor. There were no staff in the room. This was addressed immediately with a padlock fitted to the door but had not been identified as a potential issue in the daily management walk around.

Prior to our assessment we had been informed of some issues in relation to pressure mats which are used for some people to alert staff when the person has, for example, got up out of bed, not being plugged in. Whilst this had been addressed, daily walkaround records were confusing and unclear about findings in relation to the status of pressure mats.

The management team assured us this would be addressed and developed the daily walkaround records during the assessment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were recruited safely and received training appropriate to their roles. A senior member of care staff told us how newly recruited staff are supported in learning how to do the job effectively and safely. Staffing levels were above those suggested by the tool used to calculate the number of staff needed in relation to people’s needs. However, 5 of the 13 people we spoke with felt more staff were needed. Their comments included, “It is a good place, and they are good staff, but they are always short on numbers" and "Its wonderful here, the staff are great. Sometimes there are enough but other times there is no one about when you need them. They are very obliging though." Most staff felt there were enough of them to meet people’s needs safely and we did not observe people having to wait for support.

Staff told us they had received good levels of support from the deputy manager during the management changes at the service.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning their care in relation to their medication needs.

Some improvements were needed in the recording of applications of medicines prescribed to be given through a patch applied to the skin and the application of creams and lotions. This was addressed during the course of our assessment with new application charts and care plans updated.

Signatures of administration on MAR (Medicine administration record) charts needed to be clearer to make sure it was possible to clearly see if the entry indicated the medicine had been given or not and therefore make auditing easier.

Systems were in place for safe storage of medicines, and the provider accepted our suggestion to enhance this by fitting extra locked cupboards to safely store medicines recently delivered or awaiting return to pharmacy.

Protocols were in place for the use of medicines given when needed. The protocols included detail of why the medicine had been given and if it had been effective.