This inspection was carried out on 12 & 13 June 2018 and the first day was unannounced. The last inspection of the service was October 2017 and the rating for the service following the inspection was Good.

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

At the time of the inspection 47 people were living at Millbrook House.

At the time of the inspection there was no registered manager in post. The current manager has applied to us, the Care Quality Commission, (CQC), for the position of registered manager and their application is being processed. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we found the provider was in breach of Regulation 10 of the Health and Social Care Act (Regulated Activities) Regulations 2014. The breach related to people’s dignity being compromised as there were insufficient staff on duty at the time of our observations to provide care and support to people. In light of our findings we have also made a recommendation regarding reviewing the staffing arrangements in the home to ensure consistent staffing numbers at all times.

Relatives were complementary regarding the attitude of staff and the way in which they cared for their family member.

Systems were in place and followed to recruit staff and check they were suitable to work with vulnerable people.

We found the environment to be clean and free from any odour. Staff had access to protective clothing such as, gloves and aprons to support the control of infection.

The premises and equipment were subject to safety checks to ensure they were safe and well maintained. The premises was kept in good decorative order and had been adapted to support people with dementia; this included the provision of appropriate signage, colour schemes and communal areas.

People’s medication was safely managed and they received it on time and as prescribed.

Staff had a good understanding of people's individual care needs and appropriate referrals to external healthcare professionals took place. Guidance and advice that was provided was being followed; this meant that people’s overall health and well-being was being safely and effectively supported. Relatives spoke positively regarding the care and support given by the staff.

Assessments of people’s care needs had been carried out and people had a plan of care which provided guidance for staff on how to meet their needs safely and effectively. In the main these had been subject to review to check they were up to date and accurate. We found a few care records needed further information and these were updated during the inspection.

Relatives were involved in the planning of their care to support their family member and they were kept up to date with matters relating to their health and welfare.

Staff received training and support to help them support people in accordance with their individual need. Staff confirmed they received a good standard of training to support their learning and development.

Risks to people’s safety and wellbeing were recorded to enable staff to support people safely whilst promoting their independence. Accidents and incidents were recorded and an analysis undertaken to look for trends or patterns to minimise the risk of re-occurrence.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person's mental capacity was made to protect them. Th

We carried out an unannounced comprehensive inspection of this service in May 2017. We found the home to be rated ‘Requires improvement’ and we found two breaches of regulations. This was in respect of the environment as its current state made it difficult to keep hygienic to maintain standards of infection control and we found the service's existing auditing system was not robust as this had not picked up on the deficits we identified around monitoring standards of infection control and other developmental issues we discussed on inspection.

We asked the provider to take action to address these concerns. After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breach.

We undertook a focused inspection in October 2017 to check that they had they now met legal requirements. This report only covers our findings in relation to the specific area / breach of regulation. This report only covers two questions we normally asked of services; ‘Is the service safe?’ and ‘Is the service Well led?’

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

Millbrook House is a purpose built nursing home which provides care for older people with mental health care needs. It can provide care for up to 50 people and it is located in Southport.

There was a registered manager in post. ‘A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run’.

We found the service had made improvements to the environment to promote good standards of hygiene. This included refurbishment of bathroom and toilet facilities as part of the upgrade for the service. This breach had been met.

We found the service had made improvements regarding the overall monitoring arrangements for infection control and further developments were evident in respect of providing a ‘dementia friendly’ environment. We also saw evidence of the current auditing system to help monitor standards. This breach had been met.

This inspection took place on 16 & 17May 2017 and was unannounced.

Millbrook House is a nursing home which provides care for older people with mental health care needs. It can provide care for up to 42 people and it is located in Southport.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found the environment was in need to attention which made it difficult to keep hygienic to maintain standards of infection control. This was particularly evident for the toilet facilities on the ground floor which were not clean.

This is a breach of Regulation 12 (2) (h) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment.

The provider had systems and process in place to monitor and drive forward improvements. This included a number of audits (checks) for various aspects of the service. We found on this inspection that the existing auditing system was not robust as this had not picked up on the deficits we identified around monitoring standards of infection control and other developmental issues we discussed on the inspection.

This is a breach of Regulation 17 (2) (a) (b) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance

With regards to promoting a dementia friendly environment there were some appropriate wall coverings, themed décor and pictures in corridors and doors were painted in different colours to aid orientation. Some toilets and bathrooms had signage but this was not consistent in the home. There was a need for some further development to enhance the environment, particularly on the ground floor to improve accessibility, safety and orientation. We found toilet doors were locked during the inspection which meant they were not accessible for people. This was rectified during the inspection.

We have made a recommendation around the provider considering current guidance and best practice around promoting a dementia friendly environment to support people living with dementia.

The home had a consistent staff team though the numbers of staff on duty during the first day of the inspection were not in accordance with the staffing rota due to staff sickness. Staff rotas we viewed showed that in general staffing levels were consistent and staff were deployed in sufficient numbers to support people.

People were offered a varied social programme, based on individual preference. We saw social activities were meaningful and well planned at different times of the day. People told us they enjoyed what was arranged, particularly the music and cookery sessions.

External contracts were in place and internal health and safety checks and audits were completed to help maintain the safety of the building and its equipment.

Care files held thorough risk assessments to mitigate hazards to people's safety and welfare.

People had a plan of care which set out their health and social care needs. Plans of care contained person centred information, which helped to provide a holistic approach to care.

We observed staff treated people appropriately, supportively and with an understanding of their needs. We saw people were relaxed in the presence of the staff.

Recruitment procedures were robust and the required checks had been completed. Thus ensuring staff were ‘fit’ to work with vulnerable people.

Medicines were administered safely to people and the registered manager completed medicine audits to ensure the safe management of medicines.

Staff were aware of what constituted abuse and told us the procedure they would follow should they need to report an untoward incident. Training records confirmed staff had undertaken safegu

We carried out an unannounced comprehensive inspection of this service on 29 February 2016 and 2 March 2016. We found a breach of Regulation 12 Safe Care and Treatment of the Health and Social Care Act Regulations 2014. We asked the provider to take action to address this concern.

After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to this breach. We undertook a focused inspection on 7 September 2016 to check that they had they now met legal requirements. This report only covers our findings in relation to Regulation 12 Safe Care and Treatment. This covered one area whether they are 'Safe’. The other four areas 'Effective’, 'Caring', 'Responsive' and ' Well led' were not assessed at this inspection.

You can read the report from our last comprehensive inspection on 29 February and 2 March 2016, by selecting the 'all reports' link for Millbrook House on our website at www.cqc.org.uk.

At the previous inspection we had concerns regarding a lack of care planning documentation around the use of fluid thickeners. Fluid thickeners are used to support people who have difficulty swallowing, eating and drinking. At this inspection our findings showed improvements had been made in relation to this. We found people’s plan of care recorded the use of fluid thickeners to support them with their dietary requirements which meant this breach had been met.

We carried out an unannounced inspection of Millbrook House on 29 February and 2 March 2016.

Millbrook House is a purpose built nursing home which provides care for older people with mental health care needs. It can provide care for up to 42 people and it is located in Southport.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found a breach of regulation related to the provision of safe care and treatment.

You can see what action we told the provider to take at the back of the full version of the report.

All of the people that we spoke with told us that they felt their relative was safe and we saw that staff were vigilant in monitoring people’s safety.

Staff understood the different types of abuse and what signs to look out for. They also understood what to do if they suspected that abuse had taken place.

Accidents and incidents were logged and analysed by the registered manager. The records that we saw showed a good level of detail and indicated where appropriate actions had been taken to reduce risk.

During the inspection we saw that there were sufficient staff to meet people’s needs throughout the day.

Staff had received training to provide them with the skills and knowledge to provide care and support. This training had been refreshed regularly. Staff had also been given access to additional, specialist training in dementia.

People were supported to eat and drink appropriately and were offered a choice of meals.

The home was in good decorative order, but there were marked differences in the decoration and signage on each floor. This meant that the first and second floors were not dementia-friendly.

Staff treated people with kindness and compassion. They demonstrated that they understood people’s right to privacy and the need to maintain dignity in the provision of care.

The home had an activities’ coordinator who engaged people in a range of events and activities.

All of the people that we spoke with told us that the home was well managed and that communications were open and honest.

The registered manager was aware of the day to day culture of the home and current issues and priorities.

Staff knew what was expected of them and were motivated to provide good quality, safe care.

As part of our inspection we spoke with one person and a relative of a person who lived at the home. We invited them to share with us their experience of the care and support provided at Millbrook House.

The home can currently accommodate 42 people; they are in the process of having an extension built to enable this number to increase within the near future. The manager told us about the planned refurbishment of the home.

People were positive about the staff team and the care they received. Throughout the day we observed staff engaging with people in a kindly manner and involving them in decisions about activity related to their care needs. One person said, “The staff are kind and will do anything for us.” Another person told us “Visitors are always made welcome and we are treated with respect.”

The home had effective policies, procedures and systems in place to manage medicine and the administration process.

The home managed staffing levels appropriately and there were suitable arrangements in place to deal with foreseeable emergency cover.

Staff told us they felt well supported by their management and peers. They told us they were encouraged to attend training and said they worked well as a team.

As part of the inspection process we reviewed the complaints policy and procedure and found effective systems to be in place should a complaint need to be managed.

A number of people at the home were not able to tell us about their experiences, or comment about the care and support they received, due to their level of dementia. Two people did advise us they were happy living at Millbrook and they enjoyed the social activities. We spent time observing how people were cared for by the staff and we met with relatives and visitors who provided positive feedback about the home.

We spoke with family members about how the staff involved people and how they respected people’s individual choices around daily living. Their comments included, “Plenty of choice at meal times”, “There is plenty going on in the home each day”, “The staff know exactly what my (family member) needs and how to help them” ,“I can visit any time” and “The staff have asked me all about (my family member) so they know what they like to do each day.”

Relatives told us they thought the care was good and well managed. Their comments included, “I have no worries about the standard of care” and “It’s first class.”

A relative told us their family member was safe at the home as the staff were very caring.

Relatives we spoke with told us that staff knew the people living there well and that they had built good relationships with them and with the people they supported.

A professional visitor told us the staff were receptive to new ideas and when asked carried out what was asked of them to support people with their health.

We spoke with four people who lived in the home and observed some medicines being prepared and administered. Nobody raised any direct concerns about the way their medicines were handled, however, due to varying degrees of dementia we found it difficult to obtain their views. A relative told us their family member had received a review of their medication as they were in pain and this had been carried out promptly by the staff.

A relative told us the staff were good at communicating about what was going on in the home and they received regular invites to meetings about their family member, meetings about the home and had been given satisfaction questionnaires to complete. Another relative made reference to the positive changes to the environment to help people with dementia.

Relatives confirmed they were aware of the home's complaints procedure and would always speak up if unhappy about anything.

Due to the nature and level of dementia of the people living at Millbrook it was difficult to get direct opinions but we received a good level of feedback from visitors and relatives. We were also able to make general observations of people’s wellbeing, as further evidence of support and inclusion.

People spoken with generally confirmed that they felt like they were encouraged to express their views openly. They were of the opinion that these views were being taken into account by staff in the decision making for the care and treatment they received at the home. There was evidence that the home were listening to peoples views and developing the service accordingly. For example, coloured crockery had been introduced as a result of an idea expressed by a relative and this had improved the meal time experience for people.

We spoke with nine visitors who told us that staff were very good at keeping them informed about their relative’s condition which was regularly discussed with them. Although many expressed the view that people were treated with respect and dignity there were two visitors who reported varying standards of attention to personal hygiene. For example there were occasions when they had found their relative soiled and wet following attention by staff. Another reported that they had observed people wandering around who had been incontinent and they had not quickly been attended to by staff. Generally, however, those spoken with said that the staff were both competent and respectful in terms of any privacy and dignity issues and staff approached people appropriately and supported them well with respect to their overall personal care.

Those people we spoke with said that there was good communication and staff were very competent when carrying out care. Visitors told us that some of the people living at the home can present with some challenging behaviour and that generally staff responded well and this helped ensure people were kept safe.

Visitors told us that staff ensure people get reviewed if needed by the doctor [GP] or referred to a consultant psychiatrist or specialist psychiatric nurse. This liaison and support was described as excellent by one visitor.

We spoke with one person who said ‘’The staff look after me very well. They are very kind.’’ Other comments were also generally favourable [bar those mentioned previously]. The general feeling from visitors spoken with was that there had been improvements in care generally over the recent history of the home. One comment was, ‘’There’s a good staff team at the moment.’’

We spoke with a visitor who said that they are always kept informed about any changes in the care and any events such as a fall would be reported to them very quickly. Another visitor told us about how the home had been careful to organise a specialised diet and that they had taken time to ensure this was varied and appetising. This shows that the home was responsive to people’s care needs.

We received generally positive comments about the staff. Most people said they had seen a positive change over the past six months and that overall standards in the home had improved. Most felt this was down to better staffing. People did point out the remaining inconsistencies in care at times but this was balanced with comments such as:

‘’The staff are very good. They have some very difficult people and situations to deal with and do very well.’’

People in the home were not able to fully express their views as they had varying degrees of communication difficulties.

Due to the different ways that the people living at Millbrook House communicated we were not able to directly ask them their views of the care and support they received.

During our visit we met with some of the people living there. We spent time observing the support they received from staff and have taken this information into account in writing this report.

We could not directly obtain the views of people living in the home due to them having communication difficulties.

We visited Millbrook and we spoke with some of the people who lived there and also to a visitor. It was difficult to ascertain their views and informed opinion due to the progressive state of their dementia. We did ask people whether they were involved in reviewing and contributing to the care plans drawn up by staff. They said they had no involvement in this. We spoke with the manager about this aspect of involvement as the care plan is the key piece of documentation that coordinates the care in the home and although there is evidence of consent and inclusion in some areas of the care this is a key area that should be developed. We have made an improvement action [recommendation] that people should be more involved in care plan reviews.

We were told by one visitor that they could speak freely to staff and that staff did consult them on a daily basis about aspects of their relative’s care and they were also always informed when a medical review [for example] was due and what this would be about.