The Care Quality Commission (CQC) has rated Mill House in Bilston, west midlands, inadequate and placed it in special measures to protect people, following an inspection in August.
A focused unannounced inspection was carried out after receiving information of concern in relation to medicines management, infection control and staffing.
Following the inspection, as well as the overall rating for the service dropping from requires improvement to inadequate, the ratings for safe and well-led have also declined from requires improvement to inadequate. Effective has dropped from good to inadequate. Caring and responsive were not inspected and remain rated as good.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and re-inspected to check sufficient improvements have been made.
Mill House is a residential care home providing personal and nursing care to up to 24 people. The service provides support to older people, some of whom are living with dementia. At the time of this inspection there were 24 people using the service.
Andy Brand, CQC deputy director of operations in the midlands, said:
“When we inspected Mill House, we were disappointed to find a deterioration in the standard of care people were receiving. We found widespread and significant shortfalls in leadership, and the culture they created didn’t assure the delivery of high-quality care.
“It was concerning risks to people weren’t always managed safely. Where people had risks identified when they were admitted to the home, there was no assessment or actions to manage those risks. For example, some people showed signs of being distressed or agitated, and could potentially be a risk to themselves and others, however there was no guidance for staff on how to support those people which could result in them or others coming to harm.
“Also, there were no reviews of people's risk assessments when incidents happened, meaning there were no processes in place to prevent similar occurrences. For example, some people who had repeated falls, had no reviews in place to discuss what could be implemented to prevent them happening again.
“Inspectors saw that people weren’t protected from potential abuse. Injuries to people such as bruising, grazes and lumps had been identified by staff and documented in body maps. However, they hadn’t been investigated or reported to appropriate organisations which could put people at risk.
“Following our inspection, we reported our findings to Mill House so they know where we expect to see rapid improvement. If sufficient progress is not made, we will not hesitate to take further action to ensure people’s safety.”
Inspectors found:
- Window restrictors were not working properly, maintenance of beds hoists, slings and electrical equipment were not completed in a timely way
- There was insufficient staff to ensure people had their needs met when they required support
- Staff training was not consistently up to date and there was inconsistent evidence of checks on staff competency
- People's medicines administration was not consistently documented
- When incidents and accidents occurred, staff were recording these but there were no actions taken to review these and prevent reoccurrence
- People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice
- People were supported to access health professional visits however where guidance was given to support people with their health needs this was not always clearly documented within people's care plans
- CQC had not been notified of significant events as required.
However:
- People received enough to eat and drink and told us they enjoyed the food
- Recruitment processes were safe to ensure only suitable people were employed.
The report will be published on CQC’s website in the next few days.