CQC report explained · a nursing home
What the CQC found at OSJCT Millbrook Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Risks were generally identified and managed, and medicines, staffing, infection control and recruitment were handled safely. However, records about informed decisions to use reduced-height bed rails were not detailed enough, and staff needed better awareness of choking risks.
- Effective?
- Good
- People's nutrition, hydration and access to health professionals were supported. Staff had training and support, and the principles of the Mental Capacity Act were followed.
- Caring?
- Good
- Inspectors found kind and compassionate care. Staff knew people's preferences, respected privacy and dignity, and welcomed relatives and visitors.
- Responsive?
- Good
- People and relatives were involved in care planning. Activities, community links, complaints arrangements and end-of-life support were in place.
- Well-led?
- Good
- The management team was visible, approachable and focused on improvement. Audits, staff meetings and feedback were used to monitor and improve the service.
What inspectors found, May 2018
OSJCT Millbrook Lodge was rated Good; inspectors found kind, personalised care, but safety needed improvement.
The inspection was unannounced and took place on 27 February 2018. Inspectors spoke with people living in the home, relatives, visitors, staff and managers. They observed care and reviewed care records, medicines records, training files, recruitment files, complaints and audits.
The home was rated Good overall. Effective, caring, responsive and well-led were all rated Good. Safe was rated Requires Improvement. Inspectors found that risks were usually identified and managed, medicines were handled safely and staffing was generally enough.
The main safety concerns were records about people choosing to continue using bed rails that were below the recommended height, and staff awareness when supporting someone at high risk of choking. The home had improved since the previous inspection, when it was rated Requires Improvement overall.
Kind and personal care
People and relatives described staff as kind and professional. Inspectors saw staff adapt care to people's individual needs, abilities and preferences.
“Care was provided in a kind and compassionate way.” from the report
Medicines managed safely
Medicines were stored correctly, administration records were complete and staff checked records at the start of shifts.
“People received their medicines safely and clear records were kept in relation to these.” from the report
Active improvement culture
The management team used audits, meetings and feedback to identify shortfalls and improve the service. Staff were encouraged to question practice and suggest ideas.
“There were arrangements in place to monitor performance, which they continually reflected on in order to drive further improvement.” from the report
Bed rail records
needs fixingSome bed rails were below the recommended safety height because of pressure-reducing mattresses. People had been told about the risks, but the discussions and plans for managing the risks were not recorded in enough detail.
“Comprehensive information was therefore not available, to show that people had been fully supported to make an informed decision about the use of equipment which may potentially have a detrimental impact on them.” from the report
Support with swallowing risks
seriousWhen inspectors observed support with eating, staff did not always wait for the person to swallow before offering more food. The report recommended reviewing training so staff had the practical skills needed for people at high risk of choking or inhaling food.
“This increased the risk of this person potentially choking or inhaling their food.” from the report
- 01How do you now record what each person has been told about the risks of reduced-height bed rails?
- 02Are alternative mattresses or bed rail extensions now available for people using pressure-reducing equipment?
- 03What practical training do staff receive when supporting someone at high risk of choking or inhaling food?
- 04How do you check that staff wait for a person to swallow before offering more food?
- 05How do you use audits and family feedback to check that the safety improvements have been maintained?
This was an unannounced inspection of the overall service, covering all five CQC questions and both the care provided and the home itself. This explanation was written from the published report of 5 May 2018 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, March 2017
Rated Requires Improvement; inspectors found kind, personalised care but unsafe equipment and weak quality checks.
This was an unannounced comprehensive inspection on 10 and 11 January 2017. Inspectors spoke with people living at the home, visitors, staff and a health professional. They observed care and equipment, and checked care records, medicines, recruitment, training and quality records.
People generally felt safe and said staff were kind, respectful and responsive. Care plans reflected people's needs, activities were available, staff were trained, and healthcare support was arranged when needed.
However, some bed rails and one pressure-relieving mattress were not used safely. The home's checks had not found these problems. The overall rating was Requires Improvement, with Safe and Well-led also rated Requires Improvement. Effective, Caring and Responsive were rated Good.
Kind and respectful care
People and relatives consistently described staff as kind and caring. Inspectors saw people treated with dignity and compassion.
“People and relatives told us staff were kind, caring and respectful and we saw people being treated with compassion and dignity.” from the report
Personalised support
Staff knew people's preferences and routines. Care plans included personal history, choices and changing needs.
“Care plans were person centred and reflected people's changing and current needs.” from the report
Good staff training
Staff had induction, ongoing training, supervision and appraisals. Training included areas such as safeguarding, moving and handling and end of life care.
“Staff received appropriate training to carry out their roles. Staff felt supported and their performance was monitored on a regular basis.” from the report
Activities and community links
The home offered varied activities, including outings, gardening, cooking and entertainment. It also hosted community groups and visits.
“There was a range of activities that people could participate in and people were enjoying group activities on the days of our inspection.” from the report
Healthcare support
People could access GPs and specialist health professionals. Staff recognised changes in people's health and sought advice when needed.
“People could therefore be confident they received the health care support or treatment they needed at the time they needed it.” from the report
Unsafe equipment use
seriousTwo of six bed rails checked did not meet safety guidance, and one pressure-relieving mattress was set incorrectly. The problems were corrected during the inspection, but people had been exposed to avoidable risks.
“People were not always protected from potential risks caused by unsafe use of equipment.” from the report
Quality checks missed problems
needs fixingThe home's audits did not identify the unsafe equipment. A medicines check also missed a missing administration time for one medicine needing additional security.
“However, the provider's quality assurance checks were not as effective as they should be in identifying areas for improvement.” from the report
Incomplete thickener records
needs fixingFor some people at risk of choking, records did not always state how much thickening agent was needed. Inspectors were also told that speech and language therapy records could not be found during the visit.
“However, the records did not always confirm the amount of thickening required.” from the report
- 01How do you now check that bed rails are fitted at the correct height and that entrapment risks are safely managed?
- 02How are pressure-relieving mattresses checked to make sure each pump is set for the person's current weight?
- 03How do your quality audits now identify unsafe equipment use before it puts people at risk?
- 04How do you make sure records state the correct amount of thickening agent for people at risk of choking?
- 05What action was taken after the Regulation 12 breach, and what has the CQC checked since this inspection?
This was an unannounced comprehensive inspection covering all five key questions; the previous inspection was in June 2014. This explanation was written from the published report of 10 March 2017 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 OSJCT Millbrook Lodge
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- May 2018Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
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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