23 July 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
The inspection was carried out by two inspectors.
Service and service type
Millcroft House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Millcroft House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection a new manager had recently been appointed. They were in the process of registering with the CQC.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out. We wanted to be sure there would be people at home to speak with us.
Inspection activity started on 15 June 2022 and ended on 22 June 2022. We visited the location’s service on 15 June 2022.
What we did before the inspection
We reviewed information we had received from the local authority following their own visits to the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with two people who used the service and one relative about their experience of the care provided. We spoke with the cook, a senior support worker, a support worker, two occupational therapists, the new manager and the provider’s assistant director.
We reviewed a range of records. This included four people’s care and medicines records and two staff recruitment files. A variety of other records relating to the management of the service were also considered as part of the inspection. These included audits, health and safety checks and minutes of meetings.
After the inspection
We continued to seek clarification from the provider to validate evidence found following our site visit.
23 July 2022
About the service
Millcroft House is a brand-new, purpose-built residential rehabilitation service located in Seacroft, Leeds. It can support up to 10 adult males with mental health needs who have been identified as suitable for this level of shared care, or who may have experienced a breakdown in their existing placement. At the time of the inspection there were eight people using the service.
The accommodation is spread over two floors. There are four self-contained apartments, a further six en-suite bedrooms and several large communal rooms. The service has the benefit of a large enclosed garden area and is situated close to local amenities.
People’s experience of using this service and what we found
People told us they felt safe living at Millcroft House. The relative we spoke with told us, “I can’t praise the place enough.” People were supported by a range of staff, including occupational therapists and psychologists, who worked with them to help them on their road to recovery and to regain their independence. The necessary employment checks had been completed, to ensure staff were suitable to work with vulnerable people. The building was clean and well-maintained and staff followed correct infection control procedures, including wearing personal protective equipment (PPE) correctly. Medicines were managed safely.
People's needs were assessed before they started using the service and the information was used to inform person-centred risk assessments and care plans. The service used the ‘Recovery Star’ to help people using the service set goals and measure their progress to recovery. The Recovery Star is designed for adults managing their mental health and recovering from mental illness. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff had completed a range of training, and all staff received regular supervision from the management team.
The service was well managed. A new manager had recently joined the service and they were being supported by the Assistant Director and Quality Assurance Manager. We saw evidence that the management team had made changes in a number of areas and staff spoke positively about these improvements. Governance systems were in place to ensure all aspects of the service were reviewed and checked regularly. Accidents, incidents and complaints were investigated and responded to appropriately.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 19 October 2020. This is its first inspection.
Why we inspected
This was a planned inspection based on the date of registration in order to provide a rating for the service.
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 COVID-19 and other infection outbreaks effectively.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.