Milner House

Milner House is a nursing home providing accommodation, nursing and personal care to up to 46 people. The service provides support to older people with physical and health related care needs, most of who also live with dementia. At the time of our inspection there were 36 people using the service.

People’s experience of using this service and what we found

People, their relatives and staff told us the overall atmosphere in the home as well as the quality of care provided had improved since our last inspection. People felt safe in the home, received support to keep well and manage their individual risks and were supported with their medicines by safe and competent staff.

People received personalised care which considered their preferences, wishes and rights and created opportunities for meaningful engagement. People’s home environment was meeting their needs, although we discussed with the provider it could be more friendly for people who lived with dementia. We made a recommendation around dementia friendly environment which we will follow up on our next inspection. The provider addressed our feedback straight away.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff treated people with kindness and respect.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support: Model of care and setting maximises people’s choice, control and Independence;

People’s care was tailored to their individual needs and abilities and their wishes were included in the planning of their future care and what they wanted their support to achieve. At the time of the inspection a learning disability was not anyone’s primary care need.

Right care: Care is person-centred and promotes people’s dignity, privacy and human rights;

People’s rights and wishes as well as their individual needs were clearly assessed so staff provided them with individualised support. People were treated with dignity, respect and kindness.

Right culture: Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

The management of the service ensured people’s care was regularly reviewed and people received ongoing support from staff, as well as external health and social care professionals to meet their changing needs. People were involved in their care and listened to.

The registered manager knew the home well and there were clear systems in place for monitoring quality and safety of the care provided which they used effectively. Staff felt supported and involved. The management took action to improve people’s care, to resolve complaints and to complete actions identified from the provider’s quality and safety audits.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 10 October 2019).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Milner House is a nursing home that provides care to older people, people with physical disabilities and complex medical needs, which for some included living with dementia. The home is registered to provide support to up to 46 people and there were 28 people were living at the service at the time of our inspection.

People’s experience of using this service and what we found

The service had continuously improved since our last inspection. The focus had been on ensuring the service supported people in a way that was safe and personalised to people’s individual needs. Milner House still relied on the employment of large numbers of temporary staff, especially registered nurses. Whilst there was an ongoing drive to recruit more permanent staff, the progress in ensuring good documentation systems and a culture of truly reflective practice was still being embedded. The management team continued to work hard to deliver these improvements and the provider supported the service through effective governance and monitoring.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Comprehensive assessments and care plans provided the basis of personalised care and provided the foundations to ensure that staff supported people safely and in accordance with their needs and preferences. Risks to people were identified and managed in a way that balanced their safety with their right to freedom.

Staff were kind and compassionate and people enjoyed relationships with them that were fun and inclusive. Staff facilitated opportunities for people to engage in a wide range of meaningful activities. People enjoyed their meals and were supported to eat a nutritious and varied diet.

The management team championed people’s rights and worked collaboratively with each other and external partners to constantly improve the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 03 October 2018). We have used the previous rating to inform our planning and decisions about the rating at this inspection.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Milner House is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Milner House is owned and operated by Care UK Community Partnerships Ltd. It provides accommodation and nursing care for up to 46 older people. People living at the service had a variety of medical and health care needs and some were also living with dementia. The service is laid out over two floors, although at the time of our inspection, the first floor was being refurbished and was therefore not in use. On the day of our inspection 18 people were living at the service, all of whom were accommodated on the ground floor.

We last carried out a comprehensive inspection of this service on 23 November 2017 when we rated the service as Inadequate and the service was placed in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is now out of special measures.

A new manager had recently been registered at Milner House. A registered manager is a person who has registered with the Care Quality Commission 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 registered manager had worked with a regional support team to deliver improvements across the service. Some work in respect of improving record keeping and refurbishing the environment was still ongoing, but it was clear progress was being made. We will continue to monitor the service and these areas will be followed up at our next inspection. Systems for auditing were now effective in developing quality within the service and the management team were committed to completing their own plan for improvement. A key priority for Milner House now will be stabilising the new staff team and ensuring people continue to receive a personalised service as the number of people accommodated increases.

The registered manager and staff had worked collaboratively to develop principles of person-centred care, empowerment and inclusion across the service. The result of this being that people now felt listened to and involved in the planning of their care. Staff took the time to engage with people in a kind and compassionate way and support was delivered in a personalised way that was no longer task led.

There was a relaxed and friendly atmosphere within the service and people enjoyed positive and caring relationships with staff. Support was provided with patience and empathy in a way that upheld people’s privacy and dignity. People now had opportunities to spend their time doing the things they enjoyed and that were meaningful to them.

People’s needs had been properly assessed and each person had a plan of care which enabled staff to deliver appropriate support. Staff were responsive to people’s changing needs and liaised with other health care professionals to ensure they received the care and treatment they required. People were supported to make informed decisions about their end of life care and medicines were managed safely and administered as prescribed.

There were now sufficient care and nursing staff to support people safely and in accordance with their needs. Staff received ongoing training and the clinical supervision of nursing staff kept them up to date with best practice.

There were systems in place to safeguard people from abuse and the recruitment processes for new staff helped ensure only suitable staff were employed. Risks to people were identified and managed and there was now a culture of learning and reflective practice when things went wrong. The service was clean and hygienic, and the management of infection control had greatly improved.

Staff were knowledgeable about people’s individual preferences and supported them to make decisions in a way that protected their legal rights. People had choice and control over their meals and specialist dietary needs were managed well.

Milner House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Milner House accommodates up to 46 people across two floors, each of which have separate adapted facilities and some shared facilities. People living at the home had a variety of medical conditions and healthcare needs. Most of the people at the home were living with dementia. At the time of our inspection there were 24 people living at the home.

There was not a registered manager in post, one of the provider’s operational managers was in the process of registering with CQC at the time of inspection. A registered manager is a person who has registered with the Care Quality Commission 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.

People did not always receive their care safely. We observed two instances in which staff used inappropriate moving and handling techniques when supporting people. Prescribed equipment was not used which placed people at risk of injury. Where risks were identified, we found that staff were not always implementing plans to keep people safe.

Where incidents and accidents had occurred, the measures put in place to reduce the risk of them happening again were not always implemented robustly. There were not sufficient numbers of staff present to safely meet people’s needs. We observed that where people required supervision as a part of their risk management plans, staff were unable to provide this due to being busy elsewhere.

Care was not always delivered in a dignified way. Half of the people that we spoke with told us that they had encountered staff that appeared reluctant to provide support to them. People said this was a particular problem at night time and this impacted on their wellbeing significantly. There were high numbers of temporary agency staff employed at the home and they did not always know people’s needs well. People reported that staff did not take due care with their belongings and there weren’t effective systems in place to ensure people’s belongings returned from the laundry. The laundry lacked organisation and we found that linen was not stored in a way that guaranteed it would not become contaminated.

There was a lack of good practice in relation to infection control. Where infection control risks were known about one person’s medical condition, a plan was not recorded to guide staff on how to prevent cross-contamination. Staff were also observed failing to follow good practice when supporting this person. Areas of the home were not clean and systems to prevent cross-contamination were not implemented correctly.

People’s medicines were not always managed safely. Discrepancies in medicines records had been identified in an audit by the provider, but had not been addressed. We also found shortfalls in the way that medicines were stored and monitored. Nursing staff did not receive the clinical supervision that they needed and there was a lack of leadership at the home. Staff were not held to account for work that they completed and there was a lack of oversight from the provider.

People did not always receive person-centred care. Care plans contained person centred information, but we identified occasions where things that were important to people were not documented in their care plans. People told us that the activities they were offered did not cover the whole week and they often felt bored at weekends. We observed some activities taking place and saw evidence of good practice in this area, however people fed back that there was a lack of consistency.

There was a lack of leadership and governance at the home. We identified information missing from records and the provider’s audits had not identified or addressed the numerous concerns we found during our inspection.

Checks had been undertaken on new staff as well as agency staff to ensure they were suitable for their roles. Staff understood their roles in safeguarding people from abuse, however we found people were not always comfortable raising their concerns. Where complaints or concerns were raised, the provider responded to them. We recommended that the provider reviews their record keeping of complaints.

People were offered a choice of foods that reflected their dietary needs. We identified some shortfalls in the record keeping in the kitchen and recommended that the provider reviews their systems for involving people in choices about their meals. We saw evidence of people being supported to access healthcare professionals when required.

Staff followed the guidance of the Mental Capacity Act (2005). We observed times where people’s privacy was respected by staff and we received some positive feedback about staff at the home. There was a contingency plan in place to be implemented in the event of an emergency. The provider had systems in place to reduce the risk of fire and to respond in the event of an emergency. The provider had developed links with the local community that had impacted positively on people.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The service did not have a registered manager 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 previous registered manager had not been working in the service for a number of months and their registration has now been cancelled with us. The day to day management of the home was being undertaken by one of the operational support managers for Care UK who had been based at the service since February 2016.

We previously carried out an unannounced comprehensive inspection of this service on 8 and 9 February 2016. At that inspection we found a number of breaches of Regulations in respect of staffing, management, safeguarding, person centred care, nutrition and treating people with dignity and respect. As a result we issued six Requirement Actions for the service to improve. Following that inspection a number of further concerns were received about the way people had been treated by staff at Milner House. As a result we worked with the provider and our partner agencies to ensure people were safe. On 19 June 2016, we undertook a further focussed inspection to talk with people, their relatives and staff about the care people received. This inspection found that people felt happier at the service and that the provider had taken appropriate action to improve the service they received.

Since our comprehensive inspection in February 2016 we have continued to engage with the provider on a very regular basis. We asked the provider to submit regular action plans that updated us about the steps they had taken to improve the service. We also asked the provider to submit us copies of staffing information and provide assurances that safe staffing levels were maintained each week. This inspection confirmed that the provider had taken the action they told us they had. The service now had good systems in place for the monitoring and auditing of quality.

There has been a period of considerable change at Milner House this year. Whilst it was evident that the quality of care had significantly improved, the leadership of the home now needed to be embedded and sustained through the recruitment of a permanent management and staffing team. We identified that the provider lacked a clear vision about the type of service Milner House could provide moving forward. We have therefore recommended that the provider review the Statement of Purpose, taking into account the physical environment of the service as well as the skills and experience of the staff employed.

The provider had maintained safe staffing levels through the provision of agency staff. Considerable efforts had been made by the management team to ensure wherever possible the same agency staff were used and they were appropriately inducted to the service. Through the use of pen portraits, life stories and summary documents information about how to effectively support people was made available to staff who were less familiar with their needs. Whilst this was helping to provide a more consistent level of support for people, the lack of a permanent team of staff was still impacting on them.

The service had not recruited any new staff since our last inspection, but the management team had taken steps to ensure that appropriate checks were in place for the agency staff supplied. There were now good systems in place to train and support staff. People and their advocates told us that staff were more competent and provided a better care and support.

People were safeguarded from the risk of harm, because staff now understood their roles and responsibilities and knew where to go if they had concerns. The management team had introduced good systems to appropriately assess and manage the risks to people.

People’s legal rights were protected and staff ensured that they gained consent before delivering care. Where people lacked capacity to make decisions for themselves, there were processes in place to support people in line with their best interests and ensure care was provided in the least restrictive way.

Medicines were managed safely and the management team now worked in partnership with other healthcare professionals to ensure people’s needs were met in a more holistic way. People told us that they now had better access to services such as opticians and dentists. Similarly, relatives highlighted that staff attention to the little things such as nail care and hair styles were now better.

People had choice and control over their meals and were effectively supported to maintain a healthy and balanced diet. Where people had specialist dietary needs, these were known and respected. Assistance at meal times was now provided in a personalised and dignified way.

People had positive relationships with the staff who supported them and were now treated with kindness and in a way that respected their privacy and dignity. People and their advocates were actively involved in making decisions and choices about their care. Both people and their relatives said they now felt confident about expressing their feelings. The management team took appropriate steps to ensure that any concerns or issues raised were listened to, treated seriously and resolved in a timely way.

People received person-centred support and there were now good systems in place to ensure people’s needs were continuously reviewed with them and changes responded to. People had better opportunities to spend their time doing things that interested them and had access to a range of activities that were meaningful.

The service had a registered manager in post, although this person was not working at the service at the time of our inspection. 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.

We carried out an unannounced comprehensive inspection of this service on 8 and 9 February 2016 where six breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the requirements in relation to those breaches.

Since that inspection we have received a number of concerns in relation to the way people had been treated by staff at Milner House. These concerns are currently being investigated through a large scale enquiry with our partner agencies. We have been in regular contact with the provider since our last inspection and they have been providing us with weekly updates against their action plan. We decided to undertake this inspection to ensure that the information we had been given by the provider was an accurate reflection of people’s experiences of the service.

This report only covers our findings from talking to people, their relatives and staff about the care people received. We did not look at any records and we did not follow up on any of the breaches previously identified as the provider has told us that they are still working on making the required improvement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Milner House on our website at www.cqc.org.uk.

Our last comprehensive inspection highlighted that some staff were not kind and showed a lack of respect towards people. At that time, staff did not always take adequate steps to protect people’s privacy and dignity.

Since our last inspection, the provider assigned a senior management team to oversee the running of Milner House and ensure improvements were made. A large number of agency staff have also been brought in to support the service. The provider identified steps they had taken through action plans to try and change the culture within the service and ensure people’s needs were met in a kind and caring way.

At this inspection, we found that the action taken by the provider had improved the way people received their care. Whilst people and relatives highlighted the difficulties attached to the use of a large number of different staff, people told us that they felt safer now. We observed lots of positive interactions between people and staff and the atmosphere in the service was significantly more relaxed and friendly. People said that staff were kinder to them and nobody told us that they felt scared.

The provider had made key information available to staff to ensure that people’s primary needs were met. The relatives of people who had higher needs told us that they had concerns that the attention to detail was lacking because staff did not know their family members. In particular, it was highlighted that some people were not always wearing their own clothes or the right glasses.

People’s privacy and dignity were better respected. Unlike at our previous inspection, staff routinely knocked on people’s doors and waited before entering. We also saw that staff spoke directly to people and involved them in choices about their care. Support was provided in a less task focussed way because staff spent more time with people and provided care in a more considerate way.

We did not find any new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this inspection. The provider is still taking action from our last inspection, the details of these can be found by looking at that report.

The service had a registered manager 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.

We identified multiple concerns with regard to the way services were being provided at Milner House. The registered manager did not have sufficient oversight over the running of the home. Her management style was reactive and people often experienced care that did not meet their needs or expectations.

Staffing levels were insufficient and did not match people’s high levels of dependency. We found that some people had to wait too long for their care which left them feeling vulnerable and scared. Staff morale was low because some staff were frustrated that their repeated requests for additional care support was not actioned. People did not receive person centred care and felt that some staff were unkind to them as they provided support in a hurried and rushed manner.

The registered manager had not recognised that some of the concerns that people raised amounted to allegations of emotional abuse and neglect. We therefore had to direct the registered manager towards taking appropriate action to safeguard people.

People had been placed at risk because the controls in place to reduce exposure to Legionella had not been managed effectively. The registered manager had not taken appropriate steps to ensure that immediate risks were minimised and a long term solution sought to prevent reoccurrence.

Whilst most people had a choice about their food, the serving of meals was task orientated and not personalised to people’s individual routines. Specialist dietary needs and preferences were not always met because staff did not fully understand the needs of the people they supported.

The service had a programme of staff training, but closer supervision of staff was needed to ensure that learning was reflected in practice. Whilst staff knew the need to gain consent from people they lacked a good understanding about what to do if a person lacked the capacity to make a decision for themselves. Staff were also unaware of the people for whom the registered manager had assessed as potentially being deprived of their liberty which meant their care may not have been provided in the least restrictive way.

Some staff showed a lack of respect for people and their home. For example we saw that some staff did not respect people’s privacy by knocking on their bedroom doors before entering. We saw some genuine acts of compassion from staff, but not all staff had positive relationships with the people they supported.

People were not adequately supported to participate in activities that were meaningful to them. As such, most people spent the majority of their day either asleep or sat in wheelchairs. Staff were not always skilled at engaging with people, especially those living with dementia, effectively.

Formal complaints were investigated and resolved. There were limited opportunities however for people who felt nervous or were unable to raise concerns independently to express the things they felt unhappy about. These people did not feel listened to and valued.

Recent improvements to care planning meant that people’s physical needs were better assessed and monitored. Assessments however had not always been effectively transferred into robust guidelines for staff. Some staff were unfamiliar with recorded information and as such did not deliver care in the way people preferred.

The service reacted well to people’s identified health care needs and referred people to external professionals when required. There were no systems in place however to ensure people accessed preventative treatment, for example through attending routine dental checks-ups in order to maintain good oral health.

There were systems in place to manage medicines safely and ensure people received the right medicines at the right time.

Appropriate checks were undertaken when new staff commenced employment and nursing staff were supported by the provider to retain their registered professional status.

The provider had systems in place to monitor the service and had identified their own shortfalls in the quality of service at Milner House. The provider responded immediately to inspection feedback by producing an initial action plan to demonstrate how the necessary improvements would be made.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of this report.

From the observations that we made the people who used the service were comfortable and happy in Milner House. We saw relatives and people sitting together socialising and staff interacted with them in a kind and respectful manner.

We talked to the chef on the day of our inspection and observed people being served their lunch. When we asked opinions on the quality of the food we were told by one relative who visited each day 'Excellent food.'

We looked at the staffing rotas during our inspection and talked to people about staffing levels on a daily basis. We received a mixed response from everyone we spoke to. For example some staff told us they felt there was enough staff and others felt under pressure and rushed.

The provider had ensured that they made people aware of how to make a complaint should they need to. All of the people that we spoke to on the day told us they had never felt the need to make a complaint.

All people told us they were offered choices in their daily lives. We were told that staff are always talking to them and explaining things to them. We were told staff would go out of their way to be helpful and friendly.

People confirmed they felt safe living at the home. One person told us 'it's too safe as I am no longer allowed access to the balcony in my room.' This was discussed with the manager who explained this could be opened during the day.

We looked at training records for staff. We found that staff had been provided with a variety of courses to enable them to meet the needs of the people they were caring for.

Activities are provided daily and people who used the service said how much they enjoyed them. One person told us 'I choose what I do there is no pressure to attend' and another told us 'bingo is my favourite.'