CQC report explained · a residential care home
What the CQC found at Milford Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe medicines systems, suitable staffing, risk assessments and appropriate infection control measures. They also reviewed the use of unprescribed oxygen during a COVID-19 outbreak and found no evidence of harm.
- Effective?
- Good
- This key question was not inspected during this focused visit. The report says the previous ratings for areas not inspected were used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Inspectors did observe some care and support, but no current rating was given for Caring.
- Responsive?
- Good
- This key question was not inspected during this focused visit. No current rating was given for Responsive.
- Well-led?
- Good
- Inspectors found that managers understood their responsibilities, staff felt supported and relatives received regular information. Quality monitoring and learning systems were in place.
What inspectors found, April 2021
Rated Good; inspectors found safe, kind and well-managed care, but unprescribed oxygen had been used during a COVID-19 outbreak.
This was an unannounced, focused inspection on 11 March 2021. Inspectors looked mainly at safety and how the home was run, after concerns about unprescribed oxygen and the visiting pod. They observed care, reviewed records and spoke with relatives, staff, managers and healthcare professionals.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, regular risk reviews and good medicines records. Infection control arrangements were in place, including visitor screening, testing and personal protective equipment.
The provider had investigated the use of unprescribed oxygen during a COVID-19 outbreak. Inspectors found no evidence that anyone had been harmed, but the provider identified lessons and reviewed its systems to prevent this happening again. The overall Good rating also used ratings from the previous comprehensive inspection for the other areas, which were not inspected this time.
Infection control
Visitors were screened and given personal protective equipment. The home had testing, cleaning and outbreak procedures in place.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Safe staffing
The home used a dependency tool to review staffing levels. Inspectors saw enough staff and found that recruitment checks had been completed.
“We observed there were sufficient numbers of staff working during our inspection and relatives and staff we spoke with told us there were enough staff to meet people's needs.” from the report
Personalised care
Staff knew people and their needs well. Inspectors and relatives described a friendly, family-like atmosphere.
“Staff and the registered manager demonstrated a person-centred approach and knew people and their needs well.” from the report
Open management
Staff said they were supported and able to share their views. The provider kept relatives informed and notified CQC about events as required.
“The provider had a good understanding of their legal responsibilities and were open and transparent with people, relatives, staff and external agencies.” from the report
Learning and improvement
The provider investigated the oxygen incident and reviewed its systems. It also used electronic records to help identify missed care activities.
“The provider has reviewed their systems and processes to prevent reoccurrence.” from the report
Unprescribed oxygen
seriousDuring a COVID-19 outbreak, staff used oxygen before agreement with a clinician. Inspectors found no evidence of harm, but the provider said lessons needed to be learned and took action to prevent a repeat.
“The provider had carried out a comprehensive investigation and found there had been occasions where staff had used oxygen prior to agreement with a clinician.” from the report
Dated areas
minorThe provider identified some areas of the home as dated and had plans to refurbish them. The report does not say that this affected people's safety.
“The provider had plans to refurbish areas of the home that were dated.” from the report
Electronic records still being completed
minorThe move from paper records to electronic care planning was still ongoing. The provider was continuing to make sure all required information was transferred.
“The registered manager told us this was an ongoing piece of work to make sure all information required was stored on the electronic system.” from the report
- 01What changes were made after staff used unprescribed oxygen, and how do you check that oxygen is only used with clinical agreement?
- 02How far has the move from paper care records to the electronic system progressed?
- 03Which areas of the home were described as dated, and what is the timetable for refurbishment?
- 04How do you review staffing levels when people's needs change?
- 05What were the latest ratings for Caring, Effective and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led, including infection control; the other key questions were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 10 April 2021 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, November 2017
Rated Good; inspectors found kind, safe and personalised care, but some mental capacity, cleanliness and record-keeping issues needed attention.
The home provides care for up to 30 older people with complex mental health needs and dementia. At the inspection, 27 people lived there. Inspectors visited without notice on three days and spoke with people, relatives, staff and health professionals. They also observed care and checked care plans, medicines, staff records and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that staff understood people's needs, treated them with dignity, supported their health and offered personalised activities, food and care.
There were some shortfalls. Mental capacity assessments and best-interest decisions were not recorded for some important decisions about door gates. Inspectors also found dirty sluices and unclean commode pots on the first day, inconsistent records of post-fall checks and unclear instructions about thickened drinks. The report says these issues were acted on during or after the inspection.
Kind and respectful care
Staff knew people well and respected their privacy, choices and routines. Inspectors observed positive and caring interactions.
“The relationships between staff and people receiving support demonstrated dignity and respect at all times.” from the report
Personalised support
Care plans included people's likes, dislikes and routines. Staff adapted activities and support to people's mood and preferences.
“Care plans detailed people's preferences, likes, dislikes and routines.” from the report
Support for complex needs
The home worked with mental health and other professionals to understand changing needs and manage behaviour safely.
“The service worked closely with the Care Home liaison service and the Mental Health team for support.” from the report
Food and choice
People were offered meal choices, alternatives and different places to eat. Food, drinks, fruit and snacks were available during the day.
“There were good choices and fruit, fluids and snacks were seen to be readily available during the day.” from the report
Open management
Staff felt supported and had ways to raise concerns. Quality checks were used to identify and act on shortfalls.
“Quality assurance systems were in place to monitor the quality of service being delivered and the running of the home.” from the report
Mental capacity records
needs fixingFor some significant decisions, including door gates, the required capacity assessments and best-interest decisions were not recorded. The report says the paperwork was corrected after the inspection, and CQC made a recommendation for further advice.
“However, for more significant decisions, such as having door gates in front of people's rooms, mental capacity assessments and best interest decisions were not in place.” from the report
Cleanliness on the first day
needs fixingInspectors found unpleasant smells, dirty sluices and unclean commode pots on the first day. The sluice had been cleaned by the second day.
“During the first day of our inspection we found unpleasant odours within the home. The sluices were dirty and used commode pots were left uncleaned.” from the report
Post-fall records
needs fixingTwo fall records did not show the required 72-hour observations in the expected section. Staff had recorded the information elsewhere in the new electronic system, and the inconsistency was later addressed.
“Two falls we reviewed did not evidence 72hr observations after the fall.” from the report
Thickened drinks instructions
needs fixingStaff gave different answers about how much thickener one person needed. The records and a reminder sign were updated during the inspection.
“Some staff told us they would use one spoonful, other staff told us they would use two spoonful's of the thickener.” from the report
Staffing pressure
minorSome relatives felt staff were rushed or that there were not enough staff at busy times. Inspectors recorded the home's explanation about its call system and staffing arrangements.
“Well they could always do with more, it does seem sometimes as though they are short-staffed.” from the report
- 01How are mental capacity assessments and best-interest decisions recorded for door gates and any other restrictions?
- 02What checks now make sure post-fall observations are recorded fully and in the correct place?
- 03How do you make sure thickened drinks are prepared to the correct consistency and that every staff member follows the same instructions?
- 04What has changed to prevent unpleasant smells, dirty sluices and unclean commode pots?
- 05How do you make sure enough staff are available when people have particularly high or changing needs?
This was an unannounced comprehensive inspection covering all five CQC areas, using observations, discussions and reviews of care, staff and management records. This explanation was written from the published report of 25 November 2017 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 Milford Manor Care Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- April 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Goodstayed GoodSafe: GoodWell-led: Good
- May 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 January 2011.
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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