CQC report explained · a nursing home
What the CQC found at Milldene Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about visitor checks, social distancing, safe admissions, PPE and testing. They also found areas needing refurbishment and said additional cleaning rotas were required.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2021
Inspected but not rated; inspectors found good infection controls during a COVID-19 outbreak, but some areas needed refurbishment.
This was an announced, targeted inspection on 13 January 2021. Inspectors looked at infection prevention and control, including visitors, social distancing, admissions, PPE and testing. They also considered staffing.
The inspectors were assured that the home was preventing infection, using PPE safely, following shielding and social distancing rules, admitting people safely, and arranging testing for residents and staff. Visitors had temperature checks and answered questions before entering.
Some areas of the building needed refurbishment. The provider said planned work on radiators, carpets and paintwork had been delayed by the pandemic. Additional cleaning rotas were put in place during the inspection.
The home was not given an overall quality rating or a Safe rating. This was a focused review of infection control, not a full assessment of all five areas of care.
Visitor infection checks
Visitors had to have their temperature checked and answer relevant questions before entering the home.
“All visitors had to undergo a temperature check and answer a range of relevant questions before entry.” from the report
PPE and handwashing
Inspectors found there was enough PPE and that handwashing facilities were available.
“There was ample PPE and handwashing facilities available.” from the report
Safe infection arrangements
Inspectors were assured that the home was following social distancing and shielding rules, admitting people safely, using PPE effectively and arranging testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Adapted visiting space
The home changed parts of its layout to support social distancing, including creating an outdoor meeting space.
“The registered manager had repurposed areas of the home to adhere to social distancing guidance, for instance a new outdoor meeting space.” from the report
Refurbishment needed
needs fixingInspectors found areas needing refurbishment, including radiators, carpets and paintwork. The provider said the pandemic had delayed planned improvements.
“With regard to the layout and hygiene practices of the premises, there were areas in need of refurbishment.” from the report
Contingency planning
minorThe provider said lessons from the outbreak would be included in future contingency planning. Inspectors signposted resources to help develop this approach.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01Which radiators, carpets and areas of paintwork have now been refurbished?
- 02Are the additional cleaning rotas introduced during the inspection still being used?
- 03How have lessons from the COVID-19 outbreak been added to the home's contingency planning?
- 04What checks are currently made for visitors before they enter the home?
- 05How are residents and staff currently accessing COVID-19 testing and PPE?
This was a targeted inspection of infection prevention and control practices and staffing during a COVID-19 outbreak; the service was inspected but not rated and the other areas were not assessed in this report. This explanation was written from the published report of 4 February 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, December 2019
Milldene Nursing Home is rated Good; inspectors found safe, kind and personalised care, with some cleaning and building improvements still needed.
This was an unannounced inspection on 29 October 2019. One inspector spoke with four people, six staff members and two advocates. They also checked care records, medicine records, staff files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable safeguarding arrangements, safe medicines practice, enough suitably recruited staff and detailed care plans. People appeared happy and relaxed with staff, who understood their needs and preferences.
There were some areas needing improvement. Parts of the home needed extra cleaning, redecoration and upgraded flooring. Inspectors also discussed better ways to involve people in decisions and provide information. These issues were not judged to create an overall risk, and no regulations were reported as breached.
Safeguarding and medicines
The home had procedures to protect people from abuse. Inspectors saw medicines being managed safely, including controlled medicines.
“The provider had appropriate procedures in place to safeguard people from abuse.” from the report
Personalised care
Care plans were detailed and reflected people's changing needs, choices and preferences. Staff knew people's communication needs and interests.
“Care plans reflected people's needs, were detailed and reviewed and updated, as necessary.” from the report
Kind and respectful staff
People appeared comfortable with staff, who supported them with kindness, dignity and respect. Staff also encouraged independence.
“People appeared happy and relaxed in staff company and staff had a good knowledge of individual's likes and personalities.” from the report
Complaints handled
The home recorded complaints, investigated them and gave verbal and written responses explaining the outcome.
“All complaints had been dealt with fully and appropriately.” from the report
Cleaning
minorInspectors found some areas where extra cleaning was needed. The manager said this would be addressed immediately, and inspectors said it did not pose an overall risk.
“We noted some areas of the home where additional cleaning would be helpful.” from the report
Building condition
minorSome parts of the home needed redecoration, replacement carpets and new flooring. A new heating system and later refurbishment were planned.
“Some areas of the home needed redecoration and upgrading, including replacement carpets and vinyl flooring.” from the report
Involving people
minorInspectors discussed using different approaches and formats so people could have more involvement. Questionnaires were long, word-based and limited to yes or no answers.
“We discussed with the registered manager how this involvement could be improved and developed.” from the report
- 01What cleaning work was completed after the inspection, and how is cleanliness checked now?
- 02Has the planned heating work, redecoration and flooring replacement been completed?
- 03How do you help people who find written information or yes/no questionnaires difficult to take part in decisions?
- 04How do you make sure health concerns, equipment requests and professional advice are followed up proactively?
- 05How do you decide when extra staff are needed for activities or one-to-one support?
This was an unannounced planned inspection that covered all five CQC questions, including the premises and care provided. This explanation was written from the published report of 6 December 2019 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 Milldene Nursing Home
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015
Registered with the Care Quality Commission on 8 July 2015.
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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