The Mill House

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 remained 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 provision of people’s safe care and treatment.

This service scored 41 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We were concerned environmental risks identified and reported to the registered manager and provider’s representative remained present when we completed our second day of inspection. This demonstrated a lack of recognition of the seriousness of our concerns. The service’s own risk register was not an accurate reflection of people’s individual risks and support needs.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

We identified key risk information was not recorded consistently within people’s care and support records to ensure this information was accurate and available to all staff including agency, or in the event of a hospital admission. Monitoring systems in place were not consistently capturing risk, and ensuring timely action was taken to address it.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We identified some areas of safeguarding practice and investigation outcomes which demonstrated areas for improvement to ensure people and staff were protected as an outcome, with risk mitigation measures implemented and lessons learnt to reduce the risk of reoccurrence.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People living at the service had complex care and support needs, often relying on staff to identify and mitigate risk due to being unable to do so independently. Improvements to environmental risk management, as well as the accuracy recorded in people’s care and support records was not effective to protect people from the risk of harm. Inspection findings identified shortfalls in communication between staff and leaders, particularly with issues not being reported to enable maintenance to address them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We identified areas of environmental risk that had not been found through the provider’s own audits and checking systems in place. These included in relation to the condition of designated smoking areas, water temperature safety, access to hot surfaces and unsecured items within people’s bathroom cabinets. Whilst the provider took prompt action in response to our feedback, change only happened as a result of our inspection.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We identified concerns in relation to the number of staff on shift at night to support people in the event of an emergency such as an evacuation. Our findings were supported by feedback we received. A relative stated, “I would say that the nighttime and weekend staff there are not the numbers that there are during the day. The nighttime staff that are there are very good indeed.” We sourced assurances from the local fire and rescue service and the provider. We identified some areas of risk and concern within the culture of the staff team; the provider agreed to implement additional support measures for staff as an outcome of our feedback.

The provider did not always assess or manage the risk of infection.

We identified the need for staff and leaders to ensure the provider’s infection prevention and control policies were consistently followed to maintain the safety of staff and people. We identified some damaged surfaces within the care environment including on people’s seating which impacted on the ability to keep these areas clean and reduce the risk of the spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified the need for improvements to be made in relation to the oversight and management of people receiving as required medicines for the management of constipation, to ensure staff knew when to escalate concerns to the GP. This was the same for those people receiving medicines covertly (hidden in food or drink), to ensure staff were clear on when to contact the GP if the person continually refused their medicines. Improvements were made by the provider, to ensuring prescribed creams were stored securely in people’s bedrooms as an outcome of our inspection feedback.