CQC report explained · a residential care home
What the CQC found at 2 Millbrook Way
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2022
Requires Improvement; inspectors found kind, person-centred support, but concerns about restraint records, risk reviews and management checks.
Inspectors visited on 14 and 15 June 2022. They spoke with people living in the home, a relative, staff, managers and commissioners. They looked at care records, medicines, safety records, staff rotas, recruitment files and quality checks.
The home was not always able to show that people were safe. Risk plans were not regularly updated, and records of incidents involving physical intervention and restraint did not always show that lessons had been learned. Inspectors were also not assured that staff had all the right training for this work.
There were positive findings too. People had enough staff support, staff were kind and knowledgeable, and care records described people's needs and preferences well. People were supported with food, healthcare, activities, communication and decision-making.
The overall rating changed from Good at the previous inspection, published on 21 December 2020, to Requires Improvement. This was a focused inspection of Safe, Effective and Well-led. The other areas were not inspected and previous ratings were carried forward.
Enough staff
Inspectors found enough staff to support people with daily activities, including one-to-one and two-to-one support. Recruitment and induction processes promoted safety.
“The service had enough staff, including one-to-one and two-to-one support for people to take part in the activities of daily living both inside and outside of their home.” from the report
Kind, knowledgeable support
Staff appeared to understand people's needs and treated them compassionately. The staff team was described as committed and motivated.
“People were supported by a committed, caring and motivated staff team.” from the report
Person-centred information
Care records included detailed information about people's needs, preferences and what mattered to them. Single-page profiles helped temporary staff understand essential information.
“Care records included good detail about what was important to the person and how they preferred to be supported.” from the report
Out-of-date risk plans
seriousSome risk management plans were not reviewed or updated regularly. This meant staff might not have current guidance to follow.
“People had not always been supported to live safely and free from restrictions because though the provider had assessed the risks people faced they had not been reviewed or updated management plans regularly.” from the report
Restraint records and learning
seriousSome physical intervention techniques were not included in people's agreed support plans or best-interest decisions. Debriefs after incidents were not recorded, so it was difficult to see whether lessons had been applied.
“The registered manager had not recorded the outcome of any debriefs completed following incidents which included physical interventions and restraint.” from the report
Reporting injuries
seriousInspectors were not assured there was a clear process for reporting injuries caused during physical intervention or restraint to safeguarding services.
“However we were not assured there was a protocol in place to report injuries to safeguarding when they had been the result of a person who had needed physical intervention including restraint from staff.” from the report
Management checks
seriousQuality checks had not identified problems in incident records or shown that incidents were being reviewed properly.
“Oversight and reviews of incidents, which included physical interventions and restraint had not been recorded and maintained by the registered manager.” from the report
Keeping professionals informed
needs fixingSome professionals involved in people's care said they were not always kept up to date about incidents. CQC recommended that the home establish and follow a clear contact protocol.
“Some professionals involved with people living in the home reported they were not kept up to date in relation to incidents.” from the report
- 01How often are each person's behavioural support and risk plans reviewed and updated?
- 02What training have all staff completed for physical intervention and restraint, and how is their competence checked?
- 03How are incidents involving restraint debriefed, recorded and reviewed to prevent them happening again?
- 04What is the current process for reporting injuries caused during physical intervention or restraint to safeguarding services?
- 05How will the home make sure commissioners and other professionals are told promptly about incidents?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and previous ratings for those areas were carried forward. This explanation was written from the published report of 3 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2020
Inspected but not rated; inspectors found good infection control and person-centred care, but this was only a targeted inspection.
The inspection took place on 02 December 2020. One inspector visited after concerns were raised about infection prevention and care delivery. The inspector spoke with people, a relative and staff, and reviewed care records and other documents.
The home was meeting the infection prevention measures checked. Inspectors were assured about visitors, admissions, social distancing, protective equipment, testing, cleanliness and managing outbreaks.
People were seen being treated respectfully. Staff understood people's needs, supported independence and followed risk assessments. The home was previously rated Good, but this inspection was too limited to give a new rating.
Infection control
Inspectors were assured that the home had measures to reduce infection risks, including safe use of protective equipment, testing and outbreak management.
“We were assured that the provider was using PPE effectively and safely.” from the report
Respectful support
People and staff interacted positively. Staff supported people's rights, choices, independence and dignity.
“People were supported in a person-centred way that upheld their rights and promoted choice and autonomy.” from the report
Risk management
Staff used risk assessments and care plans to reduce avoidable harm while promoting independence. The provider also reviewed incidents and complaints for lessons.
“The provider reviewed accidents, incidents and complaints to see if there were lessons to be learned.” from the report
Approach needed further development
minorInspectors signposted the provider to resources to develop its approach. The report does not describe this as a breach or give it a rating.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What changes have you made since inspectors signposted you to resources to develop your approach?
- 02How do you currently prevent and manage infection outbreaks?
- 03How are people's risk assessments and care plans kept up to date while supporting their independence?
- 04What did the next comprehensive inspection assess, and have the previous Good ratings changed?
- 05How do you review accidents, incidents and complaints and make sure lessons are acted on?
This was a targeted inspection of specific concerns about infection prevention and care delivery, not a full inspection of all five key questions, so the previous ratings were not changed. This explanation was written from the published report of 22 December 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 2 Millbrook Way
2 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2018GoodSafe: GoodEffective: GoodWell-led: Good
- July 2017
Registered with the Care Quality Commission on 7 July 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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85 live-in carers within about an hour of Lancashire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 78 can care for a couple. 11 years' experience on average.
“She understands the needs of an elderly person in the early stages of dementia and has treated my mother with great kindness and skill.”
“Thanks to Tracy, Dad was always immaculately dressed and clean, his meals were all home cooked and nutritionally well balanced and his home was always kept really clean and tidy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.