CQC report explained · a nursing home
What the CQC found at Milverton Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Milverton Nursing Home rated Requires Improvement; inspectors found people were generally safe but identified weaknesses in recruitment and management systems.
This was an unannounced inspection on 06 December 2022. Two inspectors spoke with people, a relative and staff, observed care, reviewed four care records and four staff files, and checked records about medicines, incidents, premises and management.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. People had enough staff, received their medicines safely, and staff understood safeguarding. Infection control arrangements were also found to be effective.
Inspectors found important gaps in management. Some staff checks were not up to date, incident records did not always show what action had been taken, audits lacked detail, and the manager was not registered with the CQC. The manager was also not able to explain the duty of candour clearly.
Enough staff
Inspectors found staffing levels were adequate and flexible enough to respond to changing needs. Agency staff were used minimally and were familiar with the people living in the home.
“People received care and support from adequate numbers of staff deployed to meet their needs.” from the report
Medicines managed safely
Medicines administration records had no gaps or omissions. Only qualified staff could administer and record medicines, with care staff supervised by a registered nurse.
“We reviewed the Medicines Administration Records (MAR) and found these had been completed with no gaps or omissions.” from the report
Safeguarding and consent
People and relatives said people felt safe. Staff understood how to identify and report suspected abuse, and the home was working within the principles of the Mental Capacity Act.
“Staff had a clear understanding of how to identify, report and escalate suspected abuse.” from the report
Positive relationships with management
People, relatives and staff spoke positively about the management team. Staff said they could raise problems and discuss how to fix them.
“People and their relatives spoke positively about the management of the service.” from the report
Infection control
Inspectors were assured that the home was using protective equipment effectively, managing infection risks and supporting safe admissions and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff checks were incomplete
seriousOne staff member did not have a current DBS check or suitable references. Another had a DBS check dated 2013, so the provider could not be assured that all staff were suitable.
“People did not always receive support from staff that had undergone robust pre-employment checks to ensure their suitability for the role.” from the report
Management systems did not reliably identify problems
needs fixingIncident records did not always show medical intervention or action to prevent repeat events. Audits also lacked enough detail to show exactly which records had been checked.
“There was insufficient evidence at this inspection to confirm lessons were learned when things went wrong.” from the report
Manager was not registered
needs fixingThere was no registered manager in post, although plans were in place for the manager to register. The manager had been running the home unregistered for a substantial period.
“At the time of our inspection there was not a registered manager in post.” from the report
Duty of candour knowledge
needs fixingThe manager could not explain what the duty of candour meant or how it applied to their role. Inspectors recommended updating this knowledge and embedding governance systems.
“The manager was unable to tell us what the duty of candour meant and how this was relevant to their role.” from the report
- 01Have all staff now received current DBS checks and suitable references, including the staff members identified in this report?
- 02Has the manager registered with the CQC, and if not, what is the current timetable for registration?
- 03How are incidents and accidents now recorded, including medical treatment and actions to prevent them happening again?
- 04How do the new audit records show clearly which person's records and which areas have been checked?
- 05What training or support has the manager received about the duty of candour?
The inspection gave current ratings only for Safe and Well-led; the report does not give current ratings for Effective, Caring or Responsive. This explanation was written from the published report of 21 January 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, January 2021
Inspected but not rated; inspectors found infection controls were being followed after concerns about PPE and COVID-19 procedures.
This was an unannounced targeted inspection on 2 December 2020. One inspector and an Expert by Experience checked specific concerns about infection prevention and control, including PPE, social distancing and isolation.
Inspectors observed staff using PPE correctly. They found that people were protected from infection, the home was clean, and COVID-19 guidance was followed for visitors, admissions and people who tested positive. Families said they were happy with these arrangements.
The home had systems to check the quality of care and keep staff up to date. Inspectors found that managers communicated with families and staff and worked with health and social care professionals.
The home was not given a new rating. Safe and Well-led were inspected but not rated because the inspection did not cover every area. Both had been rated Good at the previous comprehensive inspection, published on 17 December 2019.
PPE and infection control
Staff had access to the right PPE and inspectors observed it being used correctly. Staff had also received training in PPE, COVID-19 procedures and hygiene.
“Staff had access to correct PPE and used it appropriately.” from the report
Safe visiting and isolation
The home checked visitors and used protected visiting arrangements. A person with COVID-19 was supported in their room and staff followed isolation guidance.
“The practices in the home minimised the risk of spread of the infection to other people using the service, staff and visitors.” from the report
Clean environment
Inspectors found the home visibly clean and free from bad smells. Cleaning and infection control audits were carried out regularly.
“The home was visibly clean and free from malodours.” from the report
Communication with families
Families said managers kept them informed about guidance, testing and cases. Inspectors also found that families were involved in decisions about COVID-19 arrangements.
“Families of people using the service were happy with the protocols put in place throughout the COVID-19 pandemic.” from the report
Earlier infection control concerns
needs fixingThe inspection was triggered by reports that PPE and COVID-19 procedures had not always been followed. Inspectors found no evidence during this inspection that people were at risk of harm from these concerns.
“We received concerns staff were not consistently wearing personal protective equipment (PPE) in line with current guidance” from the report
- 01How are you checking that staff continue to wear PPE correctly during personal care?
- 02What is the current process for isolating someone who tests positive for COVID-19 or another infection?
- 03How are visitors currently screened, recorded and supported to visit safely?
- 04How often are infection prevention, cleaning and high-touch-area audits completed, and can families see the results?
- 05How will you keep families informed about infection cases, testing and changes to visiting arrangements?
This was a targeted inspection of specific infection control concerns within Safe and Well-led; it did not assess all areas, and previous ratings for other areas were carried forward. This explanation was written from the published report of 14 January 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 Milverton Nursing Home
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2020Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- June 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2015Requires improvementstayed Requires improvementEffective: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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