Millbrow 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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. For example, the registered manager had implemented new processes regarding records and the recording of information. In some areas, this was still not being completed correctly; however, we observed how communication was implemented across the staff team and with agency staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People had an initial assessment in place before they moved into Millbrow Care Home to ensure their needs could be met. The provider had worked with local discharge teams and the local authority to ensure people were safely placed at the home.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated 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 shared concerns quickly and appropriately. For example, staff told us the correct course of action to take if they suspected abuse. One staff member said, “I would have no problem reporting this to my manager.” People were not unlawfully deprived of their liberty and any conditions on Deprivation of Liberty safeguards (DoLs) were being routinely monitored.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, each person had step by step guidance in place to support them with managing pressure areas. We saw how 1 person’s pressure wound had improved since being at Millbrow Care Home. We did raise some risk assessments, specifically around how people communicate, would benefit from being more personalised, however risk assessments contained enough detail to keep people safe.

Despite some improvements from the provider with regards to detecting potential risks in the care environment and ensuring equipment was safe, there was improvements required to the environment as a whole. For example, some areas of the home required re-decorating and the environment was not always effective to support people with dementia. The provider had recognised this in a recent audit and shared a home improvement plan with us following the inspection. Therefore we were assured this was being addressed.

The provider did make sure staff received effective support, supervision and development. Staff also worked well together. However, the provider did not always make sure there were enough qualified, skilled and experienced staff. For example, we heard call bells ringing for a long period of time before they were answered. Additionally, we observed a lack of staff in some of the communal areas. Staff we spoke with told us there was not always enough of them, and they could do with more. One staff member said “Its okay, but it is sometimes like conveyor belt care.” We fed this back to the registered manager who had recently taken steps to increase the number of staff, however recognised more was needed and agreed to look into this further.

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. The home was overall, clean tidy, and smelt fresh. There was personal protective equipment (PPE) stationed around the home and infection control audits were completed weekly to ensure compliance.

Medicines were now mostly given safely and in line with procedure, and the provider had made improvements. However, some further improvement was in the process of being implemented. For example, we observed some gaps in the recording of the application of topical medicines (creams). We could not be assured from records people had their creams applied consistently. Additionally, some protocols for medicines to be given as and when applied, often referred to as PRN, lacked some details such as when to offer PRN. This was however, recorded in a sperate care plan. We fed this information back to registered manager, who produced a recent audit which had highlighted similar concerns. We saw there was a working action plan to address this.