Mill Court 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. This is the first assessment for this newly registered service. This key question has been rated 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. The service was in breach of legal regulation in relation to the management of people’s medicines, staff recruitment, training and deployment, and duty of candour.

This service scored 44 (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 and the registered manager did not always have a proactive and positive culture of safety, based on openness and honesty. Staff did not always listen to concerns about safety or follow process to report safety events. There was a system in place for recording accidents and incidents. However, this was not consistently managed by staff and the registered manager. We found gaps in the incident forms which meant it was unclear if necessary actions were taken. There was a lack of evidence to show that the cause of accidents and incidents had been consistently investigated in line with the provider’s policy. This is important to help ensure that remedial actions can be taken to prevent similar incidents from happening again. We raised this with the management team. However, they were not able to demonstrate all required actions were completed at the time of the incidents and accidents. The provider and the registered manager did not consistently review incidents and accidents with staff to help identify themes or trends that might require further action to be taken. There were some analysis and lessons learned sessions completed. But it was not always clear if actions were completed or shared with the rest of the staff. For example, after one incident in January 2025, all staff had to complete moving and handling refresher training, but according to training information this was not fully completed.There were lessons learned for multiple medication errors however, despite these sessions we found issues with medicine management including the medicine errors continued happening. This showed the learning or action taken was not always effective to reduce the risk of such errors.

The registered manager and provider did not ensure they followed the process of duty of candour. There were incidents where the duty of candour applied. People were supported to receive the required treatment after the injuries. We reviewed information to check how the regulation had been followed when notifiable safety incidents happened. There was lack of evidence the provider and the registered manager followed the regulation and their own policy to complete all the actions set out. We could not be assured the provider had acted in an open and transparent way with relevant persons in relation to the incidents. The management team were not able to provide us further evidence this process was consistently followed and actioned.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The staff made sure there was continuity of care, including when and if people would need to move between different services. People and relatives were involved in the planning and reviewing of their care and informed and supported by the staff team. However, some of the staff noted they did not always have a good response from certain external professionals when they needed help in supporting people or managing their health. The registered manager did not always encourage effective information sharing that would support continuity of care. A member of staff said, “We always had [handover] meetings but because [the registered manager] was so intimidating, no one said anything.” Since the registered manager left the service, the management team had been working with the staff team to support them. The staff team had more leadership present that supported the direction of caring for people in their role. The management team felt staff’s confidence had improved on reporting and acting on concerns they shared with the team.

The provider did not always understand what being safe meant to people and the best way to achieve that. Staff did not always concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always ensure the system in place to protect people from abuse and improper treatment was used effectively. We found some incidents where safeguarding alerts were not raised to ensure they were investigated properly. By failing to inform the relevant authorities of the allegation of abuse, this placed people at risk of ongoing harm or abuse. This meant the provider and the staff were not fully aware of procedures to follow in accordance with the local safeguarding adults policy and procedure. As part of their role, staff must receive safeguarding training that is relevant and suitable for their role. Most of the staff completed this training. However, staff did not always demonstrate good knowledge of reporting safeguarding concerns. Staff told us when they did raise concerns with the registered manager, they were told to deal with these themselves. The registered manager did not understand their responsibilities about safeguarding people and reporting concerns to external professionals accordingly. We discussed this with the management team and they provided information on how they had been working with the staff team and people to ensure any safety concerns were reported in a timely manner. People told us staff supported and looked after them in a positive way. People told us they felt safe when receiving support from staff. They said, “I feel very safe and secure here. As you see I have a very comfy room” and “I have never felt unsafe.”
The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty. They provided us with the tracker to monitor referrals and when the outcome was known.

The provider did not always work with people to understand and manage risks by thinking holistically. Staff did not always provide care to meet people’s needs to ensure it was safe, supportive and enabled people to do the things that mattered to them. For example, one person was using an air mattress and a wheelchair. The person’s care plan noted they had a bed sensor and bed rails in place to minimise the risk of falls. We observed the bed sensor was not in the correct position and senior staff had to replace it. Another person’s care plan included signs and symptoms of hypotension, there was no record of baseline blood pressure, which limited staff’s ability to identify significant changes and provide timely and effective support. This meant lack of clear guidance on risk management could put people at potential risk of receiving incorrect care or treatment.

The provider did not always detect and control potential risks in the care environment. Not all staff received the necessary fire training including attending fire drills, to ensure they were aware how to evacuate promptly. We were not assured the staff leading on fire drills and staff training completed necessary fire marshall training. This meant the provider did not ensure this staff member was competent to manage and assess staff. We were provided with the confirmation of the course completed after the site visits. A number of fire drills were completed but, there were no fire drills completed at night. This is important to practice at night or late evening when the staff ratio was different to the day shift to ensure the staff team could confidently support people in the event of a fire.

We completed an assessment with senior staff to check if the service was designed to ensure it met the needs of people with dementia. We shared the findings with them afterwards.
We found areas of good practice to support people living with dementia, but we found some areas needed improvements. For example, people did not have independent access to snacks and finger food. The table setting in the dining lounge did not have a significant contrast in cutlery and tablecloth colours to help people see these items and be able to use it. There was a lack of signage to support people with orientation and finding different areas in the service, such as lifts, toilets, dining rooms and their own bedrooms. People’s bedroom doors had very small signage and a lack of personal photographs to help people recognise their bedrooms. The flush handles and taps in the toilets were not easily identifiable so people could use those safely. We also discussed the placement of large mirrors in these toilets were not supportive of a dementia friendly environment. We reviewed all social areas and agreed the date was not always displayed for people to enhance orientation. This meant people with cognitive problems and dementia may not always experience a supportive care environment. Other checks were completed to make sure equipment, facilities and technology supported the delivery of safe care. There were established systems for monitoring of the safety of the premises and the living environment.

The registered manager did not always operate effective and robust recruitment and selection procedures to ensure they employed suitable staff. The registered manager had not ensured all the required recruitment checks had been completed before staff started work. The recruitment records of 7 staff did not contain all the required information such as evidence from previous employment regarding staff's conduct and verifying reasons for leaving, checking full employment history and any gaps in employment. Failing to obtain all the required recruitment information before allowing staff to work, placed people at potential risk of receiving care from unsuitable staff.

The provider did not always ensure there was enough qualified, skilled and experienced staff to support people. The deployment of staff needed improving. People and relatives told us they felt there were not enough staff to support people as they heard call bells ringing and observed staff being very busy. They said, “The staff to resident ratio isn’t quite right, especially at busy times”, “I do ring the button, but it all depends how long [staff] take, as to how busy they are, they come more quickly if they’re not too busy” and “Basically, they are lovely [staff], all of them, but there are definitely not enough [of them].” The staff told us they needed more staff to complete the tasks including being able to spend some quality time with people. Staff were also asked to carry out additional tasks such as laundry or cleaning when the dedicated staff were off or not available. Our observations also confirmed issues with staffing. For example, we observed occasions when the senior staff were called to support with other tasks in the middle of administering medicines. We observed occasions of calls bells ringing continuously. Staff told us all 16 people on the ground floor needed direct staff support with personal care. Staff told us there were not enough staff to support all the people in a timely manner thus people often needed to wait longer periods. Feedback from staff was mixed about support from the registered manager and senior staff to help with tasks which also affected provision of timely care. Staff told us they have not had regular supervisions to review their role, progress and performances. We reviewed the training matrix provided and it noted a number of gaps for not updated or completed training. Staff were not always trained to support people with their specific needs. For example, people had different needs relating to dementia and different conditions such as Parkinson’s and diabetes, and catheter care. Staff were supporting people with applications of dressings. It was not clear the level of training and competency checks staff received to ensure they were able to manage this aspect of care. This meant people were supported by staff who may not have skills to meet their specific needs. After the site visit, the management team informed us they were scheduling all overdue training as a matter of urgency and continued to closely monitor this. The service had business continuity plans to ensure the service could continue in the event of an emergency.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We observed a dedicated staff team ensured the service was kept clean, tidy and malodour free. Staff followed a cleaning schedule and used appropriate personal protective equipment to help protect people from the risks relating to cross infection. This way the provider was preventing people, staff and visitors from catching and spreading infections. The service was clean, well maintained, and people said the staff were careful to wear gloves and aprons during personal care.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider needed to make some further improvements to the management of medicines. For example, some people were prescribed ‘as required’ (PRN) medicines. But not all PRN medicines had protocols in place. If people had more than 1 PRN medicine to treat the same ailment, it was not always clear which one to use first. Some people were given medicines not always according to prescription or protocol. Staff did not clearly record the rationale for this and if any further support was sought. We discussed this with the clinical development nurse to address this with staff. Staff did not always record the outcome and whether the PRN medicine was effective. Some people had patches applied to skin to manage pain, but the records were not completed properly to indicate application and removal and there was no body map in place. One of the clinical rooms had a 7-day pill box with tablets without any labels and information about the person or the contained tablets. Senior staff confirmed this should be disposed of.

We observed staff administering medicines to people respectfully and kindly without rushing people. People told us they had their medicines with staff’s support.