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

The service was not safe and remains inadequate. Not enough improvements had been made. We identified 3 breaches of the legal regulations. People did not receive safe care as care plans and risk assessments were not always in place, reviewed or updated when needed. There was no evidence of a positive learning culture within the home. There were safeguarding procedures in place however these were not always followed to ensure people were protected from potential harm. There were not enough staff available to keep people safe. There were concerns with the environment and the equipment that was used within the home. However, the home was clean, and staff were safely recruited.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team told us they used the last inspection to improve learning and the manager said, “We learn all the time”. However, when asked they were unable to provide us with specific examples of safety improvements made through learning. We were told by the manager a new safeguarding file had been introduced so safeguarding processes and incidents relating to people’s safety could be monitored. However, when we viewed this, it contained limited information and the manager told us, “We haven’t really started this yet.” Staff told us they had attended a staff meeting following the last inspection where they were made aware of the last inspection findings. However, they gave us differing views on what the findings from that inspection were and how this had a positive impact on people’s safety.

The procedures in place for learning from safety incidents were not effective. A lessons learnt log had recently been introduced, however we found this was inaccurate and not reflective of all incidents that had occurred. For example, the log showed that an incident had occurred and the manager had raised a safeguarding alert and updated the person’s care plan following this. We found these actions had not been completed and the manager was unable to account for this discrepancy. The log also identified there may not be enough staff in the home, however this had not been addressed or used to make changes. We could not be assured duty of candour was understood as the service had failed to identify all incidents and accidents and take appropriate action.

The manager told us they had ‘better’ oversight of people’s care needs. They also told us people were referred for support from other professionals when needed. Staff told us they had the opportunity to attend handover, knew where information about people was stored and used a communication book to highlight changes in people’s needs. They could give us examples of how they offered support to people.

Feedback from the local authority showed progress was being made with an action plan the service was working on. However, the action plan showed there were still areas that needed improving. For example, they acknowledged improvements with care plans however stated that the home would need to make sure that there is more resident and family involvement.

There were no specific processes in place to ensure people received safe systems, pathways or transitions. When people were unwell, they were added to the doctor’s round and seen by the GP and there was evidence referrals had been made to professionals such as the Rapid Intervention Team and Speech and Language Therapists. However, when people were experiencing periods of emotion distress there was no evidence of other professional involvement or evidence of specialist support. Although staff told us care plans and risk assessments had been updated, we found reviews of people’s care plans did not reflect up to date information such as falls or periods of emotional distress and care plans were not always reviewed when incidents had occurred. A serious incident had occurred the day prior to our inspection, this had not been documented in handover notes and therefore it had not been effectively shared with all staff.

People and relatives raised no concerns around safety. One person said, “There’s no troubles here, the people here are nice.” A relative told us, “[Person’s name] is always happy. I’ve no complaints about the treatment they get or how they look after my relation.”

Staff told us they had received safeguarding training and were able to tell us their role in raising concerns. One staff member said, “As a senior I fill in a safeguarding form and take it to the manager or deputy.” Staff were able to tell us examples of potential abuse and when they would take action. However, the manager who was responsible for overseeing safeguarding, was unable to demonstrate they understood their responsibilities to keep people safe. This included completing the required investigations to establish the circumstances around potential safeguarding incidents. They told us, “I just report what is on the incident form.” They also told us that we may find instances where potential safeguarding concerns had not been reported, when needed.

We observed that people were not free to move around the home as they chose. When people were in communal areas they were encouraged to remain in those areas. For example, when people stood up to move around, the staff member present encouraged them to sit back down, when people tried to leave the lounge, they were directed back to their seats. This could be considered as restrictive and placed people at a risk of being cared for in a manner that infringed upon their right to move freely.

There was a safeguarding policy in place however this was not always followed or understood. Not all safeguarding incidents had been investigated or reported to the local authority as required. People continued to not be protected from potential abuse. Where staff had raised concerns and completed body maps showing unexplained injuries to people, we found action had not always been taken and the manager was not aware of some of those incidents. Prior to our inspection we received feedback that an incident had occurred which meant people may be at risk of potential abuse or harm. We discussed this with the provider and manager who confirmed they were aware of the incident and had not raised or shared this with the local authority or taken any appropriate action to report or investigate it. We raised this as a safeguarding concern with the local authority. During our site visit the manager and consultant confirmed to us the home had still not taken any action to address the potential safety concern. This meant effective systems were not in place to respond to potential or alleged abuse. Deprivation of Liberty Safeguards (DoLS) which had been authorised were in files, however there were no specific mental capacity assessments to support these. The DoLS forms we saw in files had all expired with no evidence of a new application to renew. This meant people may be subject to restrictions which had not been lawfully authorised.

We received mixed views from people on their safety. One person said, “The staff walk with me, 1 at each side. I feel safe with them. Sometimes it’s only 1 member of staff, I don’t feel as safe with only 1 member of staff, but I feel safe with 2.” Another person told us, “I’ve got a walking frame. I use it all the time, since being in hospital. I use it all the time wherever I go. They give me my frame. I’m not allowed to go anywhere without it. The staff are good about that.” Relatives raised no concerns to us. No one we spoke with told us they were actively involved with their risk management.

The manager told us that care plans and risk assessments had been updated since our last inspection. They told us they had introduced monitoring sensors into everyone’s bedroom who was mobile as a ‘preventative’ measure. From discussions it was clear this had been implemented as a blanket approach and the manager had not considered the individual risks to each person when introducing this. The manager told us care plans and risk assessments had been redone and were more up to date and reflective of people’s needs. They told us they were now reviewed monthly or when changes occurred. Staff knew people well and were able to give examples of how they supported people. However, staff told us it was standard practice at the home for the standing hoist to be operated by just 1 staff member when supporting people to transfer. They told us they had not received specific training for this and were not always aware if this was in line with people’s care plans. We discussed this with the manager who told us it was a safe practice. They told us staff could complete this if people were under a certain weight and care plans reflected this. However, they were unable to demonstrate that this was in line with best practice.

We observed staff were following risk assessments for example ensuring people had the correct consistency of diet and monitoring people’s whereabouts to prevent falls. However, we saw at times that people were encouraged to remain seated in the lounge so that risks could be managed as staff had to remain in the lounge at all times.

The systems in place to keep people safe were not effective and people were placed at risk of harm. When incidents and accidents occurred within the home risk reviews were not always taking place. When reviews had been completed, it was often documented no changes had occurred and did not take into account changes or recent falls, for example. When people had displayed periods of emotional distress, we saw not all of these incidents were documented. There was not always guidance, care plans or risk assessments to show how to support people during these times. Where staff had told us they were operating the standing hoist with 1 staff member we viewed care plans for these people. We found this practice was not assessed in line with what the manager told us, placing people at an increased risk of harm. Risk assessments that were in place were followed by staff and were reviewed on a monthly basis. However, some reviews did not reflect recent changes which meant they did not always contain the most up to date information to ensure people were kept safe.

People and relatives did not raise any specific concerns about the environment being unsafe. Although one person did comment, “One issue I have is that the door doesn’t stay open by itself. I was told it was a fire hazard. So, I use my chair to keep it open. I like it open.”

The manager told us they had introduced a walk around of the building each day so they could identify and address any concerns with the environment. We found this walk round was not effective as it had not identified any of the concerns we have found under ‘observations’. We discussed these discrepancies with the manager who was unable to explain these. Staff felt the equipment was safe to use and told us they would check it and raise concerns with the manager if needed.

At our last inspection we found concerns that equipment and the environment had not been safely maintained. At this inspection we found the same concerns. We saw there were still no window restrictors in place on some of the windows, despite the provider confirming to us in an action plan this had been completed. We found hoists and other equipment’s service dates had expired and these had not been tested to ensure they were in good order and safe to use. This placed people at risk of harm. The provider took immediate action on the day of our site visit to completed this at our request. We also found electrical testing had still not been completed on all equipment to ensure it was safe to use. There were diabetic medicines stored in the ‘hairdresser’ room which was unlocked. We also found the boiler in the toilet which had exposed piping was also unlocked and people and members of the public could freely access this placing them at an increased risk of harm.

There were not always systems in place to identify concerns with the environment and equipment. For example, the manager told us they were not responsible for ensuring equipment such as hoists were tested. They told us the maintenance team was responsible for this. However, the maintenance team were not aware of this and had no oversight of this equipment. This meant this equipment had not been tested to ensure it was safe to use. The manager had no oversight of the electrical testing in the home. It took several hours for a copy of the equipment that had been tested to be located and once this was provided it had not been updated to reflect all equipment within the home. We found items that did not have evidence of testing, including televisions, lamps and hair equipment. This lack of oversight placed people, staff, and member of the public at risk of harm.

We received mixed views from people and relatives about the staffing levels in the home. One person told us, “They help me in the shower with just 1 person. I had 1 the other night. I would like a shower every day, but I can’t as there’s not enough staff.” Another person said, “They come when I press my buzzer, but I’ve hardly ever had to use it. I’m quite independent you know.” A relative commented, “Sometimes I think there could be more staff. There are times when some are doing all the work and running around, then there’s not enough staff to do other things.” Both people and relatives felt staff knew them well, had the relevant training needed and knew how to offer support to them or their loved ones.

We received mixed feedback from staff. One staff member said, “Don’t think there’s enough staff upstairs, another told us, “People use buzzers, but staff do respond. I don't think people are left waiting.” Staff felt it could be busy in a morning. They explained after the last inspection they had increased their staffing levels by 1 staff member each shift. They told us this had now reduced in an afternoon and they were concerned about this. They also told us the deputy manager was counted in the staffing numbers to provide care and support to people, however they told us the deputy rarely provided this support. Both the manager and deputy manager raised their concerns about staffing levels in the home. The manager said, “There are not enough staff”. They told us they had raised their concerns with the provider however they had failed to address this, placing people at risk of harm and/or not receiving care in a timely manner. Staff told us they had received more training since the last inspection. This included mandatory training and refresher courses.

Our observations confirmed there were not enough staff to support people. As staff had to observe people in communal areas this meant people’s whereabouts were restricted. When someone wished to leave the communal areas, we saw there were no other staff available to support so they had to remain in the lounge.

We found incidents and accidents had occurred as there were not enough staff available to keep people safe. Staff told us that a staff member needed to stay in the communal lounge to help reduce the risk of people falling. However, 1 incident recorded showed that a person had an unwitnessed fall in the communal lounge as the member of staff had to leave the lounge unsupervised whilst they supported a person away from the lounge. This incident resulted in harm to this person who was left in the unsupervised communal lounge. At the last inspection the manager was using a dependency tool to determine how many staff should be in place to support people based on their needs. However, this had pages missing and had not been used effectively. We found this had still not been addressed. We also found people’s dependency needs were not accurately recorded. For example, there were gaps missing on 1 person’s falls risk assessment as this hadn’t considered their recent falls. This meant the information that supported the staffing dependency tool was not always accurate or up to date. There was a training matrix in place to monitor staff training. However, we found there were gaps in some staffs’ mandatory training and other training such as behaviour management had not been completed. Therefore, staff did not always have the necessary skills or training to support people. Staff had received the relevant pre-employment checks before they could start working in the home. Staff had received the relevant pre-employment checks before they could start working in the home.

People and relatives raised no concerns with the cleanliness of the home. One person said, “My room is always kept clean, they keep it very clean in here.”

Staff and leaders raised no concerns with infection control and prevention (IPC). Staff told us they were aware of IPC procedures, and they knew where personal protective equipment (PPE) was stored and when it should be used. They also told us they had received IPC training. When we discussed this with the manager, they told us that since our last inspection some areas of the home which were damaged, including paint that was chipped and may pose a risk to people had now been painted over.

Although the home was clean, we saw it remained dated with some areas in a state of disrepair which posed a risk of cross infection as these areas could not be cleaned easily or effectively. During our inspection we observed staff were using PPE when needed, for example when administering medicines and serving people their meals. There was PPE in the home, and this was widely available.

There were procedures in place for infection control. However, it was unclear how infection control was monitored within the home as there were no audits in place that covered this area. Therefore, if new concerns were present, we could not be assured these would be identified.

People were happy with how their medicines were administered. One person said, “I always get my tablets”. A relative told us, “They have converted my relations medicines to liquid as they can swallow it better”.

The manager told us since the last inspection they had introduced a staff member who was responsible for medicines management. Staff who administered medicines were able to tell us the action they would take if they found an error. They confirmed their competencies were checked by the pharmacy.

We found medicines were not always safely stored. We found insulin in an unlocked cupboard. This meant the medicine was at risk of being tampered with or misused. People who had 'as required' medicines prescribed did not always have guidance in place to show staff when this should be administered. This placed people at risk of not receiving these medicines when needed. Medicines administration records were consistently completed, and we found no concerns with the recording of medicines, checks were completed on these. The manager did not have oversight of medicines as a staff member had been identified to manage this area.