CQC report explained · a nursing home
What the CQC found at Millington Springs
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's risks, staffing, safeguarding and infection control had improved. However, inspectors raised concerns about medicines storage, disposal and paperwork, although they found no evidence of harm and the manager acted promptly.
- Effective?
- Good
- People's needs and choices were assessed, staff had suitable training and people were supported with food, drinks and healthcare. Some Mental Capacity Act records lacked detail.
- Caring?
- Good
- Inspectors found kind and thoughtful care. People were treated with dignity, involved in decisions and encouraged to remain as independent as possible.
- Responsive?
- Good
- Care plans were personalised and relatives were involved. People had support with communication, relationships, activities and end-of-life wishes, although one complaint outcome was not sent in a formal letter.
- Well-led?
- Requires improvement
- New management and a clinical lead had brought clearer leadership and improvement. However, audits were not always comprehensive, action after some external audits was not prompt, and care records were not always kept at the time care was delivered.
What inspectors found, August 2021
Rated Requires Improvement; inspectors found kind, personalised care and major progress, but medicines records and management checks were not always reliable.
Inspectors visited without notice on 21 and 28 July 2021. They spoke with people, relatives and staff, reviewed care and medicines records, checked recruitment files and examined the home's safety and management systems.
There had been significant improvement since the previous inspection, which was rated Inadequate. People were described as safe, well cared for and treated with dignity. Care plans were personalised, staff supported people's choices, and food, drinks, activities and healthcare were managed well.
The home still needed to improve its checks and records. Inspectors found concerns about medicines storage, disposal and paperwork, as well as incomplete care recording and audits that had not identified every problem. The overall rating was Requires Improvement, with Safe and Well-led also rated Requires Improvement.
The home had been in Special Measures since April 2021. It is no longer rated Inadequate, no longer in breach of regulations and is no longer in Special Measures.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed gentle, patient support that respected dignity and encouraged independence.
“People were supported with thoughtfulness and kindness by caring staff.” from the report
Personalised support
Care plans recorded people's needs, preferences and communication methods. Relatives were involved in planning care.
“People's plans of care were personalised and detailed with their individual needs and preferences.” from the report
Better safety arrangements
Risk assessments, staffing arrangements, safeguarding processes and infection control had improved since the previous inspection.
“Risk to people were being identified, assessed and managed well.” from the report
Good food and hydration support
The cook knew people's dietary needs and preferences. Staff encouraged people to drink, particularly in hot weather.
“People were supported to eat and drink well. At mealtimes we observed people were supported with dignity.” from the report
Clearer leadership
A new manager and clinical lead had brought more structure and had worked through an improvement plan after the previous inspection.
“Since the last inspection a new manager and clinical lead had started.” from the report
Medicines records and storage
needs fixingInspectors found concerns about how medicines were stored and disposed of, and about related paperwork. The manager addressed these concerns promptly and inspectors found no evidence of harm.
“On the day of inspection, we did raise some concerns around the storage of medicines, disposal of medicines and paperwork relating to medicines.” from the report
Management checks missed problems
needs fixingAudits were in place but did not always identify concerns, including some medicines issues. Action after external audits was not always prompt.
“However, we found these audits were not always comprehensive, for example they had not identified some of concerns we found around medicines.” from the report
Some legal records lacked detail
minorSome Mental Capacity Act documentation did not clearly record the views of relevant people, including relatives, even though consultation was noted.
“We did find some of the MCA documentation lacked some detail.” from the report
- 01What changes have been made to medicines storage, disposal and record keeping since the inspection?
- 02How do managers now check that audits identify medicines and other safety problems?
- 03How are staff being supported to keep care records up to date at the time care is delivered?
- 04Who is currently responsible for managing the home, and has the application for manager registration been completed?
- 05How are relatives' views recorded in Mental Capacity Act decisions and care planning?
This was an unannounced planned inspection covering all five key questions, including infection prevention and control arrangements. This explanation was written from the published report of 7 August 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, April 2021
Rated Inadequate and remains in special measures; inspectors found serious ongoing safety and management failures.
This was an unannounced focused inspection on 23 February and 4 March 2021. Inspectors checked whether earlier legal requirements had been met, looking mainly at Safe and Well-led. They reviewed care and medicine records, staff files, management records and infection control. They also spoke with people, relatives and staff.
The home remained unsafe. Inspectors found medicines were not managed properly, risks involving PEG tubes, catheters, behaviours and the building were not controlled well, and infection control was inadequate. There were also concerns about agency staffing and recruitment checks.
The home was not well-led. Audits and investigations did not reliably identify or resolve problems. There was no registered manager, and the provider had not submitted the action plan requested after the previous inadequate inspection.
The overall rating stayed Inadequate, as did Safe and Well-led. The home remains in special measures, meaning CQC will keep it under review and normally re-inspect within six months to check for significant improvement.
Some people felt safe
Inspectors found that staff knew the safeguarding processes and that people felt safe, although the systems for preventing harm were not reliable.
“Whilst staff were aware of safeguarding processes and people felt safe” from the report
Positive staff and family feedback
Some staff, people and relatives spoke positively about the care and relationships with staff. Feedback was mixed overall.
“I think all the staff are very hard working and very caring.” from the report
Incidents were usually reported
The provider understood its responsibility to be open about incidents and informed relevant agencies. Investigations were seen for most incidents, although some were not timely.
“They ensured they informed the relevant agencies, such as the local authority and CQC.” from the report
Medicines were not safely managed
seriousRecords were missing important information, including allergies, PRN instructions and administration signatures. Inspectors also raised concerns about covert medicines, overuse of PRN medicines and skin patches.
“Medicines were not being safely managed.” from the report
Risks were not controlled
seriousCare plans and checks for PEG tubes, catheters and behaviours that may challenge were not sufficient. Trip hazards, hot water temperatures and mattress checks also remained unresolved.
“Risk assessing, monitoring, management and mitigation continued to be insufficient and placed people at increased risk of harm.” from the report
Infection control was inadequate
seriousStaff did not always use the correct PPE, new admissions were not always isolated as required, and PPE disposal and cleanliness were not consistently managed.
“Best practice guidelines for preventing the transmission of Covid-19 were not always being followed” from the report
Staffing and recruitment concerns
seriousThe home relied heavily on agency staff and did not have enough competent permanent senior staff. All five staff files reviewed had gaps in employment history or suitability information.
“We reviewed five staff files and found gaps in each one.” from the report
Weak management checks
seriousAudits were not always completed or did not identify risks. Actions were not followed up, and accident and incident information was not analysed promptly.
“Audits continued to not always be completed or, where they had, they had not always identified risks and concerns.” from the report
Communication was inconsistent
needs fixingSome relatives were unsure about the management structure and said communication was lacking. Feedback questionnaires had not been analysed or used to address concerns.
“However, relatives did voice some concerns over the lack of communication and were unsure about the current management structure.” from the report
- 01What specific changes have been made to medicines records, including allergy information, PRN instructions, signatures and skin-patch checks?
- 02How are PEG tubes, catheters, behaviours that may challenge and environmental hazards now assessed and checked?
- 03What has changed in infection control, including PPE use, admission isolation, PPE disposal and cleanliness?
- 04How are you reducing reliance on agency staff and checking the competence and recruitment records of all staff?
- 05Who is currently managing the home, and how are audits, incidents and relatives' feedback now reviewed and followed through?
This was a focused inspection of Safe and Well-led, including infection control; the other key question ratings were not assessed and were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 7 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.
Every inspection of Millington Springs
4 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- August 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- January 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- February 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017
Registered with the Care Quality Commission on 12 June 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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