CQC report explained · a residential care home
What the CQC found at Millwater
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some medicines were not managed safely. Risks linked to flammable creams, medicine patches and some as-required medicines had not always been properly assessed or recorded.
- Effective?
- Good
- People's needs and choices were assessed, staff were trained, and people received suitable support with food, drink and healthcare.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people well and supported their independence and involvement in decisions.
- Responsive?
- Good
- Care was personalised and records contained information about people's preferences, communication and relationships. People were supported with activities, religion and cultural traditions.
- Well-led?
- Requires improvement
- Management systems had improved, but medication audits had not identified the concerns found by inspectors. The home remained inconsistent in assuring high-quality care.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found kind, personalised care, but medicines safety and some management checks still needed improvement.
Inspectors visited on 2 August 2023 without announcing the visit and returned on 7 August. They spoke with people living at the home, relatives and staff. They observed care and checked care records, medicines records, recruitment files and management checks.
People were generally treated kindly and supported to make choices. Staff knew people well, care was personalised and people had access to health professionals, activities and important relationships. The ratings for Effective, Caring and Responsive were Good.
Medicines were not always managed safely. Checks had not found all the problems inspectors identified. The home remained in breach of Regulation 12 and received an overall Requires Improvement rating. This was the second time it had received this rating.
Kind relationships
People and relatives spoke positively about staff. Inspectors saw caring relationships and staff who knew people's needs well.
“People and staff had developed positive meaningful relationships. Staff knew people well and demonstrated a kind and caring approach.” from the report
Personalised support
Care plans included people's likes, dislikes, important relationships and communication needs. People were involved in decisions about their care.
“Staff knew people well and care records contained detailed information which helped them to provide responsive care.” from the report
Choice and independence
People were supported to make daily choices, maintain privacy and remain as independent as possible. Mental capacity requirements were followed.
“People were supported to have maximum choice and control of their lives.” from the report
Staffing and safeguarding
People and relatives said there were enough staff. Recruitment checks were completed safely and staff understood how to report safeguarding concerns.
“We saw staff were attentive and responded promptly to people's requests for assistance.” from the report
Medicines were not always safe
seriousSome medicine patches were applied to the wrong area, patch locations were not recorded and instructions for some creams and as-required medicines were incomplete. Inspectors said this placed people at risk of harm.
“Systems and processes were not sufficient to demonstrate people's medicines were managed and administered safely. This placed people at risk of harm.” from the report
Management checks missed problems
needs fixingThe home had strengthened its checks, but medication audits had not identified the medicine concerns found during the inspection. This meant opportunities to improve had been missed.
“Medication audits had not identified the concerns we found.” from the report
Some areas needed refurbishment
minorParts of the building were tired and some surfaces were difficult to clean. Refurbishment work was scheduled to start in September 2023.
“We saw some areas of the building were difficult to clean. For example, some paintwork and the plaster on walls was chipped.” from the report
- 01What changes have been made to check that medicine patches are applied to the correct place and rotated safely?
- 02How are staff told where prescribed creams must be applied, and how is this checked?
- 03What written protocols are now in place for medicines prescribed to be given as required?
- 04How are medication audits now tested to make sure they identify problems before someone is put at risk?
- 05What refurbishment work was completed after the planned start in September 2023?
This was a follow-up care home inspection covering all five key questions, including infection prevention and control, with the inspection visits taking place on 2 and 7 August 2023. This explanation was written from the published report of 20 September 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, July 2019
Requires Improvement; inspectors found serious gaps in medicines safety and oversight, although staff were kind and the home was working to improve.
Inspectors visited on 21 and 22 May 2019. The first visit was unannounced. They spoke with people living at the home, relatives, staff and a professional. They checked care plans, medicines records, recruitment files and management records.
All five areas were rated Requires Improvement. Medicines were not always given as prescribed. Some risk information was out of date, nutrition monitoring was not always followed, and staff training was incomplete or overdue.
Inspectors found that staff were kind, promoted privacy and independence, and provided varied activities. However, people were not always given information in an accessible format, care reviews were overdue, and there were missed opportunities for meaningful engagement.
The home did not have a registered manager. Its systems for checking quality had failed to identify important problems. The provider was given warning notices to become compliant by 24 July 2019.
Kind and respectful staff
People told inspectors that staff were kind and treated them with dignity. Staff knew people's histories, wishes and preferences.
“People spoken with told us staff were kind and treated them with dignity and respected their privacy.” from the report
Safe staffing
Staffing levels were set according to people's needs. Recruitment checks, including DBS checks, had been completed.
“Staffing levels were set consistently with people's dependency needs to ensure that they were supported safely.” from the report
Independence and activities
People were supported to make choices and do things for themselves. Inspectors saw people using the kitchen and found activities in the home and community.
“There was a strong emphasis on the provision of activities that were meaningful to the people living in the home.” from the report
Improving management structure
Staff and relatives said the new management team was more approachable and that the home had improved in recent months.
“There was now a clear management structure in place and staff were aware of who to report any concerns to.” from the report
Medicines were not consistently safe
seriousInspectors found that medicines were not always given as prescribed. Instructions were contradictory, and monitoring of medicine storage temperatures was incomplete.
“We found medicines management systems were not always safe. People were not always administered their medicines as prescribed and monitoring systems were not robust.” from the report
Risk information was out of date
seriousSome risk assessments and emergency evacuation plans did not reflect people's current needs. Inspectors also found an unlocked cupboard containing substances that needed secure storage.
“However, some of the information was out of date or inaccurate.” from the report
Training was incomplete or overdue
needs fixingMany staff had not completed autism or learning disability awareness training. Some safeguarding and infection control training had not been refreshed for several years.
“We found 12 staff, in post prior 2019, were yet to complete training on autism awareness and 17 staff yet to complete learning disability awareness training.” from the report
Nutrition monitoring needed improvement
seriousOne person was not weighed as often as their care plan required. A large weight loss for another person had not been investigated.
“Weights for another person fluctuated considerably for example, they had lost 10.7kg in four weeks but this had not been investigated further” from the report
Accessible communication was limited
needs fixingPeople were not consistently given care information in pictures, easy read or other formats they could understand. This reduced their involvement in choices and care planning.
“Information was not consistently provided in accessible formats to enable people to understand and make choices.” from the report
Quality checks did not find problems
seriousThe provider's checks had not identified concerns about medicines, records, weight loss, equipment, staff training and communication. This was a breach of the good governance regulation.
“The provider's quality assurance systems had not identified issues we found across the service; including but not limited to the concerns with medication, accurate record keeping and weight loss.” from the report
- 01What has changed to make sure every person's medicines are given exactly as prescribed and recorded correctly?
- 02How are current risk assessments, emergency evacuation plans and health instructions checked and updated?
- 03Have all staff completed current autism, learning disability, safeguarding and infection control training?
- 04How are people's weights and nutritional needs now monitored, and what happens when there is unexpected weight loss?
- 05What accessible information, such as pictures or easy read documents, is now available to help people make choices about their care?
This was a planned inspection covering all five key questions, including the care provided and the premises; the first day was unannounced and the provider knew inspectors would return on the second day. This explanation was written from the published report of 6 July 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 Millwater
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016
Registered with the Care Quality Commission on 8 December 2016.
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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