Miles House - 4 Hentland Close

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 meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, medicines management and safety of the environment.

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 consistently promote a culture of safety and learning. Staff did not always listen, report or investigate concerns about safety events. Staff failed to act on feedback from people regarding how they were being cared for, and lessons were not routinely learned to support continuous improvement or embed good practice. The provider had failed to identify and act on areas of care where people’s safety, privacy and dignity were negatively affected. This meant the provider was unable to identify, mitigate and learn from incidents or concerns.

The provider worked with people and healthcare partners to establish and maintain continuity of care. There had been no recent admissions to the service, and the people living there had been resident for many years. The registered manager explained that, when admitting a new person, they would gather detailed information about them and consider whether they would be compatible with the existing group. Hospital passports were in place and contained essential information to support safe transfers to other facilities, enabling staff to provide effective continuity of care.

The provider was not effective in ensuring people were safeguarded from harm or abuse and had failed to make sure people were supported to understand what safe meant to them. One person told us they did not always feel safe due to how another person’s anxieties were manged by staff and the potential of them coming to harm. Relatives we spoke with also gave mixed views on the safety of their loved ones in the service. Where there were concerns or incidents the provider was not consistently notifying the relevant agencies including CQC. This meant there was a lack of external scrutiny over events where people had come to or there was potential of harm. This meant the provider could not demonstrate compliance with their legal responsibilities.
During the inspections we found incidents that had not been recognised or reported as safeguarding, retrospective notifications to safeguarding and the CQC were completed by the provider following our inspection.
We found gaps in staff knowledge and application of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). Some staff could not demonstrate a good understanding of how to support people who lacked capacity, or how to ensure that restrictions were lawful, proportionate and regularly reviewed. This meant we were not assured that people were consistently enabled or supported to have choice in their care and support. Not all restrictions placed on people had been identified or recorded in their care records. This placed people at risk of having their rights overlooked or their liberty restricted without the correct legal authorisation or oversight. During our visit, we raised four safeguarding referrals with the local authority due to concerns about people’s safety and the provider’s failure to recognise and report these incidents themselves

The provider did not always work well with people to understand and manage risks. People’s individual risks were identified and assessed; however, the quality of assessments were inconsistent. Paper and electronic records did not always align, meaning staff did not have access to accurate and consistent information to support people safely. For example, 1 person who received their nutrition via a percutaneous endoscopic gastrostomy (PEG) had outdated guidance in their paper records which conflicted with the up to date care plan held on the electronic system. This increased the risk staff may follow incorrect instructions. Not all staff felt care plans and risk assessments gave them enough guidance on how to manage risk. A staff member told us, “I think some care plans need more accurate detail”. Despite this, we found some risks were well managed and monitoring records were in place to keep people safe. The registered manager told us people were supported to take positive risks. For example, staff supported 1 person to go out, despite their anxiety increasing the risks, because it mattered to them.

The provider did not always detect and control potential risks in the care environment. During our visit, refurbishment work was taking place in the kitchen. Cupboard and drawer doors had been removed, which left hazardous substances and knives accessible. A risk assessment had not been completed to manage these risks. When we returned on the second day of our visit, the doors had been replaced; however, hazardous items remained unlocked. This meant people were exposed to avoidable environmental risks. Although the service had processes to carry out regular checks of the environment and equipment, these were not always effective. A health and safety audit completed in December 2025 did not identify the risks we found during our visit. Following our visit, the provider assured hazardous substances had been safely locked away.

The provider ensured recruitment checks were completed before staff started work. This included checks with the Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions. staff had received regular support through team meetings and one to one supervision sessions. Staff told us the felt supported by the registered manager.

The provider did not always assess or manage the risk of infection effectively. They did not consistently detect infection risks or demonstrate how they controlled the risk of it spreading.
Environmental layout and equipment did not always support safe infection prevention and control. Clinical waste had to be carried through a food preparation area to the clinical waste bin. On the first day of our visit, the bin was not lidded or foot operated. Although the provider replaced it before our return visit, it was still not foot operated and remained in the same unsuitable location. This meant the risks had not been fully addressed.Food was not always stored or labelled appropriately, which meant staff could not ensure food safety or prevent contamination. When we returned, we found some improvements had been made. Airtight containers had been purchased to stored opened dry foods and staff had started to record open dates. The environment was not always kept clean or maintained to support good infection control. We observed drink spillages on walls and skirting boards. Staff used sponges to wash up, which increased the potential for cross contamination. Protective covers on 1 person’s bedrails were worn and no longer impervious, meaning they could not be effectively cleaned and posed an infection risk.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not consistently ensure the safe management of medicines. Where people required ‘as required’ (PRN) medicines, the provider had not put guidance in place. This meant we could not be assured that people were always getting their medicines in line with their prescribed needs. We raised this with the registered manager and, when we returned, PRN guidance had been developed for all relevant medicines. The registered manager was aware of the principles of STOMP (Stopping Over Medication of People with a Learning Disability, Autism or Both). However, having reviewed records we could not be assured there was not an overuse of 1 person’s PRN medicine. This did not demonstrate an approach to ensuring least restrictive practice in the delivery of care.The provider also failed to ensure medicines were stored safely. We found some medicines were not securely locked away, and some did not have recorded open dates, which meant staff could not monitor expiry. Staff monitored temperatures for medicines requiring refrigeration, however, when temperatures fell outside the recommended range, they did not record any actions taken to address this. These shortfalls increased the risk people may receive medicines that are not used, recorded or managed in line with best practice.