CQC report explained · a residential care home
What the CQC found at Milligan Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were supported by enough experienced staff and medicines were managed safely. However, some environmental repairs, infection control actions and incident records were not fully complete.
- Effective?
- Good
- People's health, eating, drinking and consent needs were supported well overall. Staff received training and worked with health and social care professionals.
- Caring?
- Good
- The report does not give a separate Caring rating. Inspectors said people received individual support and that staff knew people well.
- Responsive?
- Good
- The report does not give a separate Responsive rating. Inspectors described support for people's choices, independence, social inclusion and relationships.
- Well-led?
- Requires improvement
- Management systems and support plans had improved, but incident management, environmental actions and infection control monitoring needed further development.
What inspectors found, October 2023
Milligan Road rated Requires Improvement; care and medicines improved, but safety checks and management systems were not yet consistent.
This was an unannounced follow-up inspection on 12 September 2023. Two inspectors and an Expert by Experience visited the home. They spoke with staff, observed care, checked the building and equipment, and reviewed care plans, risk assessments, medicines records, training and management records.
The overall rating was Requires Improvement. Safe was Requires Improvement, Effective was Good, and Well-led was Requires Improvement. Inspectors found that people were generally supported by staff who knew them well, and that medicines, healthcare, food and staff training had improved.
Some important work was still unfinished. Inspectors found environmental repairs and infection control shortfalls. Records about incidents, known triggers and learning from incidents were not always complete. The new systems had improved, but needed more time to become consistent and lasting.
The previous inspection, published in March 2023, had found breaches relating to safe care, safeguarding, consent and governance. This inspection found that those previous breaches had been met. However, the overall rating remained Requires Improvement because further improvements were still needed.
Safer medicines
Prescribed medicines were managed and given safely. Staff had detailed instructions, received refresher training and had competency checks.
“Prescribed medicines were ordered, managed, stored and administered following best practice guidance.” from the report
Staff knew people well
There were enough experienced and competent staff to meet people's assessed support needs. Staff and relatives were positive about staff deployment and skills.
“People were support by sufficient numbers of experienced and competent staff.” from the report
Health support
People were supported to attend health appointments and information was shared with other professionals. Emergency information was detailed, current and accessible.
“Staff worked in partnership with health and social care professionals to maintain people's health and wellbeing.” from the report
Choice and daily life
People were supported to make choices, stay active, maintain relationships and develop independence as far as possible.
“People received care and support that met their individual needs and choices.” from the report
Known risks not always recorded
seriousA known trigger affecting one person's anxiety and behaviour was missing from their support plan. Inspectors said this left staff without guidance and increased the risk of harm to that person and others.
“This meant staff did not have guidance of how to manage this known risk and therefore put the person and others at increased risk of harm.” from the report
Building repairs
needs fixingInspectors found several problems, including broken guttering, missing plaster, a damaged radiator protector and a missing window tie. Actions had started but were not finished.
“Improvements were required to both external and internal areas.” from the report
Infection control checks
needs fixingCleaning checks did not cover some PPE levels or soap dispensers. There were no red bags for soiled linen, and some actions from a local authority audit were unfinished.
“We were not fully assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Incident records and learning
needs fixingRecords did not always describe behaviour and strategies used before physical intervention or PRN medicines. Debrief meetings and analysis of patterns were not always completed.
“Further action was required around analysing themes and patterns to support learning to reduce reoccurrence.” from the report
- 01Which repairs identified during the inspection have now been completed, and what is the timetable for any remaining work?
- 02How do you check that support plans include every known trigger and the correct guidance for staff?
- 03How are incident records, debrief meetings and patterns or trends reviewed now?
- 04What has been done to complete the infection control actions, including soap checks, red bags and separating clean and soiled laundry?
- 05How do you check that the new management and audit systems are now consistently used and sustained?
This was an unannounced follow-up inspection covering Safe, Effective and Well-led; separate Caring and Responsive ratings were not given in this report. This explanation was written from the published report of 3 October 2023 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, March 2023
Rated Requires Improvement overall, with Well-led Inadequate; inspectors found serious problems with medicines, risk management, consent and oversight.
Inspectors made an unannounced, focused inspection over three days. They checked Safe, Effective and Well-led, spoke with staff, observed care and reviewed care plans, medicines records, risk assessments, training and management systems.
They found that risks were not always assessed or managed. Some people did not receive medicines as prescribed. Records and guidance for diabetes, medicine patches and medicines given when needed were incomplete or unclear.
The home did not always follow the Mental Capacity Act. Records about people's decision-making abilities were conflicting, and some restrictions were not properly supported. Safeguarding concerns, incidents and chemical restraint were not consistently investigated or reviewed.
The overall rating fell from Good to Requires Improvement. Safe and Effective were rated Requires Improvement, while Well-led was rated Inadequate. Caring and Responsive were not inspected in this visit, so their previous ratings were carried forward.
Relationships
Inspectors saw positive engagement between people and staff. People and staff described the home as friendly and homely.
“Good relationships were noted between people and staff and positive engagement was seen.” from the report
Choice and activities
People could choose where to spend their time and were supported to go shopping, eat out and take part in activities.
“People were seen choosing where they wanted to spend their day either in their own rooms or communal areas.” from the report
Food choices
People helped choose meals and shop for food. Inspectors found food storage and management met best practice guidance.
“People were involved in choosing their food, shopping and planning their meals.” from the report
Medicines
seriousPeople did not always receive medicines as prescribed. One person received a different dose without authorisation, and guidance for medicines given when needed was not always clear.
“People did not always receive their medicines as prescribed.” from the report
Risk and health records
seriousSome risk assessments were out of date, and care plans did not give staff enough information about diabetes and other health needs. Monitoring records were also incomplete.
“Risks to people were not always fully assessed or mitigated by the provider.” from the report
Consent and restrictions
seriousMental capacity records were contradictory, and some DoLS conditions were not met. This meant people could face unnecessary restrictions or not have their rights properly protected.
“The provider had not complied with the principles of the Mental Capacity Act.” from the report
Safeguarding and incidents
seriousSafeguarding concerns and incidents were not consistently investigated, reviewed or used to identify patterns. Chemical restraint was not always documented.
“There was no evidence of investigations or outcomes completed by the provider to assess the safety of the service and prevent future occurrences.” from the report
Leadership and oversight
seriousManagement checks did not identify or resolve serious problems. Records were difficult to find, and meetings with people and relatives had not taken place for several months.
“There was a significant lack of governance and oversight of the quality of the service provided to people.” from the report
Cleanliness and waste
needs fixingA mattress was heavily soiled, cleaning records were incomplete and the clinical waste bin was unlocked and overflowing during the inspection.
“The external clinical waste bin was observed to be unlocked on all 3 days of inspection.” from the report
- 01What action has been taken to make sure medicines are given at the prescribed dose and that PRN guidance is personalised and clear?
- 02Have all people's risk assessments and health care plans, including diabetes plans and monitoring records, now been updated?
- 03How are safeguarding concerns, incidents and the use of chemical restraint now recorded, investigated and reviewed for patterns?
- 04How are mental capacity assessments and DoLS conditions checked to prevent unnecessary restrictions and protect people's rights?
- 05What evidence can you show that the new management and governance systems have fixed the problems identified by inspectors?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 11 March 2023 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 Milligan Road
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- March 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Registered with the Care Quality Commission on 1 August 2013.
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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At least 100 live-in carers within about an hour of Leicester
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 £1,270 a week. 83 can care for a couple. 12 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
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