Archived: Milton House

Milton House is a residential care home providing personal care to four people at the time of the inspection. The home can accommodate up to six people in one building and there are multiple communal areas. They predominantly support people living with a learning disability and/or autism.

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

The provider had not established an effective system to ensure people were protected from the risk of abuse. Risks to people's health and wellbeing had not been monitored or mitigated effectively. People were at risk of harm because staff did not always have the information, they needed to support people safely. A number of safety concerns in relation to the environment were identified. The service was not always clean. Medicines were not managed safely, and medicine administration records were not always complete. The provider had not ensured there were sufficient numbers of competent and skilled staff to support people safely. Fire risk was not managed safely. At our last inspection we found safeguarding incidents had not always been reported as required to the local authority. At this inspection we identified a continued lack of reporting of safeguarding incidents.

At the last inspection we found care plans and risk assessments lacked sufficient detail to ensure people were supported safely. At this inspection we found improvements had not been made. We observed care plans and risk assessments continued to lack sufficient detail to support people safely.

People were not protected from the risks of COVID 19 and other infectious disease and we could not be assured the provider was making sure infection outbreaks could be effectively prevented or managed.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. 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.

Based on our review of key questions safe and well-led, the provider was not able to demonstrate how they were meeting the underpinning principles of Right support, right care right culture. The service was not maximising people's choices, control or independence. People were not always supported to make meaningful choices. There was a lack of person-centred care and people's human rights were not always upheld. A lack of timely action by leaders to ensure the service was well staffed and safeguarding incidents were responded to meant people did not lead inclusive or empowered lives.

People were not given regular opportunities to discuss their individual care needs or wider issues in the home. People had care plans in place. However, these were not always written in a way that was person-centred and easy to understand. We observed people were not always supported in an open, inclusive and empowering way.

Systems in place to promote staff learning and development were ineffective. Improvements were not clearly identified.

The service was not well led. At our last inspection the quality assurance systems to assess and monitor the service were not always in place, and where they were, they were not effective. At this inspection we found the provider did not have enough oversight of the service to ensure it was being managed safely and quality maintained. Quality assurance processes had not identified all of the concerns in the service and where they had, sufficient improvement had not taken place. Records were not always complete. People and stakeholders were not always given the opportunity to feedback about care or the wider service. Indicators of a closed culture were identified, and staff morale was low. This meant people did not always receive high-quality care

The provider had failed to notify CQC of significant events that happened in the service as required by law.

The provider had not displayed their rating for Milton House within 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 and update

The last rating for this service was Inadequate (published 28 September 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had not been sufficient and the provider was in breach of nine regulations, eight of which were continued breaches.

This service has been in Special Measures since 16 August 2021.

Why we inspected

The inspection was prompted in part due to concerns received about information shared being incomplete or inaccurate, withholding of information, people not being supported appropriately to prevent them from becoming distressed, lack of communication between the nominated individual and staff, incidents not being taken seriously and responses to safeguarding enquiries not being met. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service remains inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well-Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to staffing, person-centred care, safe care and treatment, management of risk, safe management of infection prevention and control, safeguarding people from abuse, safe management of medicines, premises and equipment, duty of candour, assessing and monitoring risk, good governance, failure to display ratings and failure to report to CQC.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Milton House is a residential care home providing personal care to four people at the time of the inspection. The home can accommodate up to six people in one building and there are multiple communal areas. They predominantly support people living with a learning disability and autism.

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

People were at risk of harm due to poor medicines management. We could not be sure people had received their medicines safely and as prescribed.

Infection prevention and control was not always effective and safe. Staff were not disposing of PPE and LFD tests in line with government guidelines.

Care plans and risk assessments did not always contain enough information to guide staff how to support people safely and effectively.

People were not always safeguarded from abuse and incidents had not always been reported to the relevant people.

Agency staff who were used regularly, had not received appropriate training to enable them to carry out their role safely.

Staff were not always recruited safely, there were gaps in employment histories which hadn’t been checked. We have made a recommendation about this.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. 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 not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Choice and inclusion were not effectively promoted, so people using the service were not leading as full lives as possible. People were not actively involved in making decisions around their care and the environment in which they lived. The ethos, values, and behaviours of the provider and care staff did not ensure people using the service led confident, inclusive and empowered lives. People did not always receive person centred care and the lack of a consistent management team had a negative impact on people’s lives.

The care people received did not always promote people’s dignity, privacy and human rights. For example, we witnessed an inappropriate and unauthorised physical intervention taking place which had the potential to harm the person and did not promote dignity.

People we spoke to identified they were scared or could not relax due to the noise and behaviour of one person. The nominated individual had recognised this and planned to be working at the service full time until a registered manager could be appointed.

The provider had not displayed their rating for Milton house on their website.

Governance systems had not identified the concerns we found during our inspection. We could therefore not be assured that quality assurance processes were effective.

There was a lack of management oversite of the service, staff lacked direction which impacted on people leading confident, inclusive and empowered lives. Staff told us the lack of management oversight had impacted on people and behaviours that challenge had increased as a result.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (Published 17 November 2020). The service remains rated requires improvement. This service was been rated requires improvement for the last inspection and inadequate for this inspection.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made, and the provider was still in breach of regulations.

Why we inspected

We received concerns in relation to failure to report safeguarding incidents, financial management, medicines management and safe staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Milton House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe management of medicines, management of risk, safe management of infection prevention and control, safeguarding people from abuse, assessing and monitoring risk, staffing, good governance, failure to display ratings and failure to report to CQC.

We have imposed conditions on the providers registration which requires them to submit a monthly report to the Care Quality Commission on the actions being taken to ensure improvements are being made to quality and safety of the service.

Follow up

We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.

Milton House is a residential care home providing personal care to five people at the time of the inspection. The home can accommodate up to six people in one building and there are multiple communal areas. They predominantly support people living with a learning disability and autism.

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

People were at risk of harm due to poor medicines management. We could not be sure people had received their medicines safely and as prescribed.

Infection prevention and control was not always effective and safe. Staff were not wearing PPE in line with government guidelines.

Governance systems had not identified the concerns we found during our inspection. We could therefore not be assured that quality assurance processes were effective.

Staff were recruited safely, and staffing levels met the individual needs of people, meaning people received the support they required in a timely way. Staff knew how to keep people safe from harm.

Staff demonstrated a commitment to providing person-centred care based on people's preferences and wishes. The staff team, including agency staff used regularly, knew people well and had built trusting relationships with them.

Staff had received appropriate training and support to enable them to carry out their role safely.

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 guidance CQC follows 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.

The registered manager and staff described how people living at the service were the focus of their work. The culture in the service was improving and staff were supported to place people at the centre of all decisions about their lives and the environment they live in.

Where communication was a barrier, on-going support was being developed to improve communication between staff and people, so that people’s voice could be heard and acted upon.

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 01 May 2018).

Why we inspected

We received concerns in relation to the culture of the service and the safety of people when applying deprivation of liberty safeguards. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Following this inspection, the provider took action to mitigate the risks and address the concerns found. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Milton House on our website at www.cqc.org.uk.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This inspection took place on 22 March 2018 and was unannounced. This was the first inspection of the service following its registration in April 2017.

Milton House provides personal care and accommodation for up to six adults with complex learning disabilities and mental health illness. Some people were also living with sensory issues, physical disabilities and behaviours that may cause harm to themselves or others. At the time of our inspection there were three people using the service.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support CQC policy and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. This service had been adapted to suit the individual complex needs of the people who lived there.

People living at the service were not socially excluded due to their behaviours because they were enabled to live their chosen lifestyles with intensive specialised care from staff. People had moved to this service within the last year from other services.

The building was spacious and airy and has been designed with input from behaviour support specialists to meet individual needs. The service had a communal kitchen, dining/lounge room and secure garden.

There was a registered manager in place. 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 were safeguarded from avoidable harm. Staff adhered to safeguarding adults procedures and reported any concerns to their manager and the local authority.

Staff assessed managed and reduced risks to people’s safety at the service and in the community. There were sufficient staff on duty to meet people’s needs. Staff understood and practiced the principals of Positive Behavioural Support (PBS). A method of supporting people who display, or are at risk of displaying, behaviour which challenges.

Staff were able to recognise that harmful behaviours were also a form of communication.

The provider gave people the opportunity to share their views by training staff to understand people's communication styles, using objects of reference and collecting detailed data about people’s moods, facial expressions and body language.

Safe medicines management was followed and people received their medicines as prescribed. Staff protected people from the risk of infection and followed procedures to prevent and control the spread of infections.

Staff completed regular refresher training to ensure their knowledge and skills stayed in line with good practice guidance. Staff shared knowledge with their colleagues to ensure any learning was shared throughout the team.

Staff supported people to eat and drink sufficient amounts to meet their needs. Staff liaised with other health and social care professionals and ensured people received effective, coordinated care in regards to any health needs.

Staff applied the principles of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. An appropriate, environment was provided that met people’s needs.

Staff treated people with kindness, respect and compassion. They were aware of people’s communication methods and how they expressed themselves. Staff empowered people to make choices about their care. Staff respected people’s individual differences and supported them with any religious or cultural needs. Staff supported people to maintain relationships with families. People’s privacy and dignity was respected and promoted.

People received personalised care that meet their needs. Assessments were undertaken to identify people’s support needs and these were regularly reviewed. Detailed care records were developed informing staff of the level of support people required and how they wanted it to be delivered. People participated in a range of activities.

A complaints process was followed to ensure any concerns raised were listened to and investigated.

The registered manager had not informed us of events that potentially impacted the safety and welfare of people at the service. This meant we had no information to enable us to monitor the safety of the service. We have made a recommendation about this.

An inclusive and open culture had been established and the provider welcomed feedback from staff, relatives and health and social care professionals in order to improve service delivery. A programme of audits and checks were in place to monitor the quality of the service and improvements were made where required.

Further information is in the detailed findings below.