Archived: Millvina House

Updated 22 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The first day of the inspection was carried out by 3 inspectors, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second day was carried out by 1 inspector and the third day was carried out by 1 inspector who remotely reviewed records.

Service and service type

Millvina House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Millvina House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with 6 relatives about their experience of the care provided and 1 person who lived at the home. We spoke with 5 members of staff including the manager, nurses, senior care workers, care workers and the director of quality.

We reviewed a range of records. This included 9 people’s care records, and multiple medication records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 22 September 2023

About the service

Millvina House is a residential care home providing nursing and personal care to 42 people at the time of the inspection. The service is registered to support up to 60 people in one adapted building, located over 3 floors.

People’s experience of using this service and what we found

We have made a recommendation about the recording of medicines. This is because although the provider was no longer in breach of regulation, medicines administration records (MARs) were untidy and confusing, and it was not always clear if people had received their medications as prescribed.

We have made a recommendation in relation to records. This is because although care plans were personalised, we identified gaps in monitoring records, such as repositioning charts and food charts. We could not be certain people had received the care interventions reflected in their care plans.

Leadership, governance and oversight was much improved at this inspection. There were still some improvements required in relation to records. We identified concerns with areas of care provision that had not been picked up by the providers routine audits. The provider employed a new management team after the last inspection. People told us they liked the new manager. The new management team and governance processes needed further time to fully embed.

Systems to effectively manage risk assessments had improved. People’s care needs and associated risks had been assessed and there was more in-depth information in place to help keep people safe from harm.

Systems to determine safe staffing were in the process of being updated and we received some mixed feedback with regards to staffing levels. Relatives were mostly happy with the care their loved ones received. However, some still felt staffing levels needed to be improved. Our observations found there were generally enough staff to meet people’s needs. However, there were still some periods of time where the communal lounges were left unstaffed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Accidents and incidents were recorded and action was taken to mitigate risk following safety related events. Safeguarding referrals were made when needed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 21 February 2023)

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

This service has been in Special Measures since 21 February 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Millvina on our website at www.cqc.org.uk.

Enforcement and recommendations

We have identified breaches in relation to good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.