Millfield 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 safe care and treatment and staffing.

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 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.

Incidents and accidents were appropriately reported, recorded and analysed to learn when things went wrong. The service reviewed contributory factors and trends to improve the quality of care and people’s outcomes, including any changes needed to their care. One person had recently fallen and as a result staff had worked with them to discuss additional safety measures which were put in place including a referral to a specialist team. Another person had managed to leave the service when it was not safe for them to do so and as a result the provider identified additional staffing was required to support them safely.

Staff were involved in the learning process and in implementing any actions needed to ensure people’s safety. One staff member told us “We have teams meeting to discuss incidents. Staff get information about how it will be resolved or prevented again”.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There was clear guidance and pathways in place setting out how staff would work with other stakeholders to safely support people’s health and care needs. These included people having regular checks on long term conditions and information on how staff should respond if this deteriorated. Professionals who worked with the home spoke of positive and proactive relationships with one stakeholder explaining “I visit regularly. I have no concerns at all. The home communicate well and are very friendly. People seem to be happy and there are always things going on.”

Where people needed enhanced physical or emotional support to access healthcare appointments this was provided by staff. For example, one person had a fear of medical professionals, and there was clear guidance on how staff should manage healthcare appointments in a sensitive way that supported this person. They now had greater confidence attending health appointments as a result and described to inspectors the techniques staff use to reassure them.

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.

Where there were concerns people had been subjected to abuse or neglect, the provider acted with integrity by reporting these incidents and worked in partnership with other organisations to ensure people were safeguarded from harm. One professional who worked with the service told us “The manager has gone over and above what is expected from her role to support the person I work with. They raised the concern on their behalf and has advocated and liaised with people alongside them and continues to do so. The person I work with has nothing but praise for the service and the care they receive.”

People expressed they felt safe living at Millfield House with one person telling us “Absolutely, not a problem. I feel super safe.” All staff had been trained in safeguarding and were knowledgeable about how to safeguard people. They could confidently described signs of concern and how they would report these. One member of staff told us “I would notice signs such as becoming withdrawn, marks on the body, cagey about reasons, might become more sexually overt, or becoming possessive over their items. I would escalate it up to the manager”.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service were meeting the principles of the MCA.

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

We found that risk assessments were regularly reviewed, and largely effective at protecting people from risks posed by their health and care needs. However, we found that not all risks had been identified and documented to guide staff to keep people safe from harm.

One person took medications alongside alcohol as a personal choice, for which they had mental capacity to do so. However, by taking these together they were placed at a greater risk of feeling drowsy or sleepy and of heart related complications such as hypotension. These placed this person at higher likelihood of harm. There was no clear guidance for staff on the specific risks posed by each medication when taken with alcohol, including any warning signs they should look for, or steps to protect this person from harm.

Another person who had a risk of choking was prescribed a softer diet which was documented in their care plan. However, some staff we spoke to were not aware of this person requiring a modified diet. We observed one member of staff supporting this person to eat while visibly unsure of what do, which caused this person to cough. The daily notes showed they were being given food items that did not align with their prescribed diet and significantly increased their risk of choking. There was no information recorded by staff to demonstrate how the food had been modified in line with guidance to ensure it was safe to eat.

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

Although there was an evacuation plan that showed how staff should support people to safety during a fire, staff we spoke to lacked appropriate knowledge and gave inconsistent responses. Most people had physical disabilities meaning they relied on evacuation sledges or mats to leave the building, however most staff we spoke to had not been shown how to use these. A trained fire marshal was not on duty at every shift who could lead an evacuation. Accounts given to us of how evacuations would be undertaken differed between staff and were not safe or achievable. This raised significant risks of people coming to harm in case of a fire. The manager also stated they were concerned about fire safety and told inspectors, “I agree the situation is unsafe. I don’t think we have enough staff at night to manage this safely given people’s needs.” After the inspection the provider put in place an additional member of staff to ensure this could be managed safely.

The premises were largely well maintained, with appropriate monitoring of equipment and crucial utilities such as electricity and gas to ensure this remained the case. However, we identified some hazards such as overloaded sockets which increased the risk of fire and hot taps in some areas that posed a scalding risk, which were resolved when raised with the service.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

There were insufficient staff assessed as competent to perform key care tasks such as administering medication. This was a particular concern at night where only 1 member of the night staff team had been determined competent to give medication. This meant, during these times, we were not assured people would receive urgent support if required, or from staff with an appropriate level of training.

Staff were not consistently knowledgeable about people’s needs which increased the risk that people would receive care that was unsafe or did not align with best practice. For example, some people required adaptions to their diet because they had either diabetes or a choking risk. However, staff either told us there was either nobody requiring a different diet or identified incorrect people. Staff gave differing accounts of their responsibilities to evacuate people during a fire and were not aware of how to use the equipment provided. Where people had restrictions on their care to ensure their safety, staff told us they were not aware of these restrictions or gave us the names of people where there were no lawful restrictions on their care.

Appropriate recruitment processes were followed including use of Disclosure and Barring Service checks (DBS). A DBS check is a criminal record used by providers to make safer recruitment decisions.

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.

There was a high standard of cleanliness at the service, and regular checks to ensure this remained the case. Staff were trained and knowledgeable about their responsibilities to keep people safe from infections. They supported people to maintain their own personal hygiene in a way that was person centred and promoted independence.

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

Although we identified most medication practices were safe, we found there were not enough staff trained to give medication safely when people needed it. This raised concerns that people would not be able to access “as and when” medication immediately, for example, in response to pain or exacerbation of a health condition. One staff member shared an example of when they had supported a person in the community but had to cut short their visit so they could return to the service. This was because they were the only member of staff on shift who could give medications. This showed a negative impact on people’s ability to take part in day-to-day life in the way they wished. Another member of staff who worked at night told us, “I don’t know who is currently trained to give medications on the shifts I work,” before giving the name of another staff member who also was not trained.

Medications were safely recorded, stored and documented with regular audits taking place to review this. Staff who did administer medications had received robust competency assessments to ensure they were able to do so safely. The risks posed to people by their medications were largely safely managed, but there needed to be clearer guidance on how the risks posed by taking medications together with alcohol should be managed where that was people’s choice.