About the service: Millstream House provides care and support for up to 22 people who have a diagnosis of Huntington's Disease and acquired brain injury. The home is set out over three floors, with lift access throughout. Some people had mobility difficulties, sensory impairments and some received their care in bed. At the time of our inspection, 20 people were using the service.

People’s experience of using this service: The service had improved since we last inspected it. Everyone we spoke with was positive in their feedback. Comments included; “I feel safe living here, yes very safe. The staff and other people living here make me feel safe”, “The staff make me feel good. I like them” and “I would give it 9/10 [when 10 is excellent and 1 is poor]. The best thing is that all the people are friendly. I wouldn’t change anything.”

People were safe at Millstream House. Staff knew what their responsibilities were in relation to keeping people safe from the risk of abuse. The provider followed safe recruitment practices. One person said, “I feel safe here because the staff are all very good.”

Staff encouraged people to actively participate in activities, pursue their interests and to maintain relationships with people that mattered to them. They felt a part of their local community and were supported to use local resources to their advantage.

Staff understood the importance of promoting people’s choices and provided the support people required while promoting and maintaining independence. This enabled people to achieve positive outcomes and promoted a good quality of life.

People were involved in the running of the service and were consulted on key issues that may affect them.

People received the support they needed to stay healthy and to access healthcare services. Each person had an up to date support plan, which set out how their care and support needs should be met by staff. These were reviewed regularly.

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

Rating at last inspection: Requires Improvement (Report published 14 March 2018).

Why we inspected: At our last inspection, we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was in relation to our finding, which showed that records keeping had not improved in the service. We also made recommendations in relation to inadequate medicine administration record keeping and that the provider and manager seek advice and support, for the organising of stakeholders’ meetings within the service.

We asked the registered provider to take action to meet the regulations. We received an action plan on 05 April 2018, which stated that the registered provider would take action to meet the regulations by 30 August 2018.

At this inspection, we found that improvements had been made in relation to the requirement made above and the recommendations.

Follow up: We will continue to monitor the service through the information we receive. We will carry out another scheduled inspection to make sure the service continues to maintain a Good rating.

The inspection was carried out on 06 February 2018, and was an unannounced inspection.

Millstream House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Millstream House is a residential care home located in Strood. The home provides accommodation for up to 22 people who have a diagnosis of Huntington’s Disease and acquired brain injury. The home is set out over three floors, with lift access throughout. Some people had mobility difficulties, sensory impairments and some received their care in bed. 18 people currently used the service.

At the last Care Quality Commission (CQC) inspection on 01 and 02 December 2015, the service was rated Good in Safe, Effective, Caring, Responsive and Required Improvement in Well Led domains with overall Good rating. Records had not been updated, they were not consistent and well organised. We made a recommendation to the provider.

At this inspection, we found the service Requires Improvement.

There was a new manager at the service. The new manager started four weeks before we inspected. The new manager was undergoing registration with the Care Quality Commission. 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 and associated Regulations about how the service is run.

Systems were in place to enable the provider to assess, monitor and improve the quality and safety of the service and these were being followed. The provider was aware of the concerns we found at the last inspection. However, records continued not to be maintained accurately completed and contemporaneous in respect of each person.

Medicines practice was not always safe. Medicines had not always been adequately recorded. Hand written MAR chart had not been counter signed by a second member of staff to confirm what the GP had prescribed. We have made a recommendation about this.

Residents, staff and family meetings were not held regularly. We have made a recommendation about this.

Staff knew what their responsibilities were in relation to keeping people safe from the risk of abuse. Staff recognised the signs of abuse and what to look out for. There were systems in place to support staff and people to stay safe.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The provider and staff understood their responsibilities under the Mental Capacity Act 2005.

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

People received the support they needed to stay healthy and to access healthcare services.

There were enough staff to keep people safe. The manager continued to have appropriate arrangements in place to ensure there were always enough staff on shift.

Each person had an up to date, personalised support plan, which set out how their care and support needs should be met by staff. These were reviewed regularly.

People were supported to eat and drink enough to meet their needs.

Staff encouraged people to actively participate in activities, pursue their interests and to maintain relationships with people that mattered to them.

Staff received regular training and supervision to help them to meet people's needs effectively.

Staff showed they were caring and they treated people with dignity and respect and ensured people's privacy was maintained particularly when being supported with their personal care needs.

The manager ensured the complaints procedure was made available in an accessible format if

The inspection was carried out on 21 March 2017 and was an unannounced inspection.

Millstream House is a residential care home located in Strood. The home provides accommodation for up to 22 people who have a diagnosis of Huntington's Disease and acquired brain injury. The home is set out over three floors, with lift access throughout. Some people had mobility difficulties, sensory impairments and some received their care in bed. At the time we visited there were 14 people living at the home.

At the last Care Quality Commission (CQC) inspection on 01 and 02 December 2015, the service was rated overall Good and Requires Improvement in ‘Well Led’ domain.

We carried out an unannounced comprehensive inspection of this service on 01 and 02 December 2015. We made a recommendation about audits which had not quickly identified and responded to gaps in records which had not always been completed. Further, there was not a registered manager in post.

We undertook this focused inspection to check and to confirm that had made improvements. This report only covers our findings in relation to our recommendation. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Millstream House on our website at www.cqc.org.uk.

At this inspection, we found that there was a registered manager 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.

Staff meetings took place on a regular basis. Minutes were taken and any actions required were recorded and acted on. Staff feedback was sought and used to improve the care.

The registered manager provided good leadership. They checked staff were focussed on people experiencing good quality care and support. People and staff were encouraged to provide feedback about how the service could be improved. This was used to make changes and improvements that people wanted.

There were effective systems in place to monitor and improve the quality of the service provided. We saw that various audits had been undertaken. The registered manager and provider regularly assessed and monitored the quality of care to ensure standards were met and maintained. Records were clear and robust.

Further information is in the detailed findings below.

We inspected this service on 01 and 02 December 2015. This first day was an unannounced inspection while the second day was announced.

Millstream House is a residential care home located in Strood. The home provides accommodation for up to 22 people who have a diagnosis of Huntington’s Disease and acquired brain injury. The home is set out over three floors, with lift access throughout. Some people had mobility difficulties, sensory impairments and some received their care in bed. At the time we visited there were 12 people living at the home.

At our last inspection on 09 March 2015, we made recommendations and found that the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to the regulation 9, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk because sufficient numbers of staff were not deployed. Records had not been suitably maintained. People did not always get food and fluid which met their individual needs and the planning and delivery of care did not always meet people’s needs. We asked the provider to send us an action plan on how and when they planned to improve the service and meet the regulations. The provider submitted an action plan to show how they planned to improve the service and meet the regulations by 30 October 2015. We found they had met this deadline.

There was not a registered manager 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. However, the operations manager informed us that the current acting manager would be submitting an application to register as manager.

The manager and provider regularly audits that assessed and monitored the quality of care to ensure required standards were met and maintained. However, the audits had not quickly identified and responded to gaps in records which had not always been completed. We have made a recommendation about this.

People were protected against the risk of abuse; they felt safe and staff recognised the signs of abuse or neglect and what to look out for. Staff understood their roles and responsibilities to report any concerns and were confident in doing so.

Risk assessments were in place that identified and reduced risks that may be involved when meeting people’s needs. There were risk assessments relating to people’s individual needs and details of how the risks could be reduced. This enabled staff to take immediate action to minimise or prevent harm to people.

There were sufficient numbers of suitable staff to meet people’s needs and promote people’s safety. The provider and manager followed safe recruitment practices to help ensure staff were suitable for their job role.

Staff had been provided with relevant training and they attended regular supervision and team meetings.

The Care Quality Commission (CQC) monitors the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the manager understood when an application should be made and how to submit one and was aware of a recent Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty.

Health care plans were in place and people had their health needs regularly monitored. Regular reviews were held and people were supported to attend appointments with various health and social care professionals, to ensure they received treatment and support as required.

People were supported to have choices and received food and drink at regular times throughout the day. Alternatives were provided for people as they wished.

Staff were caring and we saw that they treated people with respect during the course of our inspe

The inspection took place on 09 March 2015 and it was unannounced.

Millstream House is a residential care home located in Strood. The home provides accommodation for up to 22 people who have a diagnosis of Huntington’s Disease and acquired brain injury. The home is set out over three floors, with lift access throughout. Some people had mobility difficulties, sensory impairments and some received their care in bed. There were 14 people living at the home.

The home had a registered manager. 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.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 came into force on 1 April 2015. They replaced the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People said they felt safe living in the home. One person told us, “Staff are very good here and I am happy”. Relatives told us that their family members received safe care.

There were insufficient numbers of staff working at the home at times. Every person had high levels of care and support needs and required additional support when accessing the community. Staff had to complete other tasks which reduced the time they were able to spend with the people.

Staff were clear about their roles and responsibilities and knew who to report to if they suspected abuse. The safeguarding policy did not detail the names and numbers of organisations that abuse should be reported to and did not link to the local authority multiagency safeguarding vulnerable adult’s policy, protocols and guidance. We have made a recommendation about reviewing safeguarding policies and procedures.

Each person had an individual risk assessment. However, these had not always been updated or reviewed when people’s needs changed to make sure they were protected from harm. We made a recommendation about reviewing and updating risk assessments.

When people required their food and fluid intake to be monitored this was not always recorded clearly. One person’s drink had not been thickened in accordance with the dietician’s advice and placed the person at risk of choking and dehydration.

Some people’s care plans had been reviewed and updated regularly to reflect changes in people’s health. However, some care plans had not. Staff would not have up to date details on each person’s care needs. Records were not always maintained to acceptable standards. We found records that had not been completed accurately.

There was a complaints procedure in place. Information about how to complain was displayed in the entrance lobby so that people knew how to make a complaint. People were asked about their views through meetings and annual surveys. Complaint investigation records were not available for us to view so we were unable to check what the details of complaints investigations.

There were procedures to follow in the event of a fire so that staff knew how to protect and evacuate people. The home was clean, tidy and well-presented following redecoration. A healthcare professional told us that the home’s décor had significantly improved and was light and airy. Maintenance records showed that repairs were carried out promptly.

Medicines were stored and administered safely so that people received the medicines they needed.

The provider followed safe recruitment procedures to ensure that staff working with people were suitable for their roles. Staff had received training relevant to their role and had the skills and competence to provide care and support to people. Staff received good support from their manager and regular supervision.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Best interests meetings had taken place with relevant people. Where people were subject to a DoLS, the registered manager had made appropriate applications. The registered manager understood when an application should be made was aware of a Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty.

Staff understood how to protect people’s rights. Where people had difficulty communicating staff knew how to communicate in ways people could understand. Staff listened to and respected decisions made by people. People’s care files included personalised decision making profiles and a decision making agreement. These showed how relatives were involved when people lacked capacity.

People were offered a choice of meals and were given regular drinks throughout the day. There was plenty of food including appropriate foods for people with a specific dietary requirement. The cook understood how to fortify foods for people at risk of malnutrition. People’s weight had been regularly monitored and their nutritional needs had been reviewed by healthcare professionals.

People received medical assistance from healthcare professionals including district nurses, optician, chiropodist, psychiatrist and their GP. They attended hospital appointments when needed. The home worked closely with a local hospice to ensure that people’s preferences and choices for their end of life care were recorded.

People were treated with respect and dignity, kindness and compassion. Their personal records were stored securely.

People gave mixed feedback about the activities available. The activities coordinator organised a range of activities for people to choose from. However, people who were not able to verbally communicate spent periods of up to two hours at a time with no engagement in activities.

Relatives told us that they had been involved with developing and reviewing care plans. They told us they could visit at any time and were kept informed about their family member. Care files included detailed assessments of people’s needs and reflected what people could do for themselves. People’s daily records showed that staff had provided responsive care which met their needs.

People felt the home was well run. Staff felt confident to raise concerns if they had any. They were aware of the whistleblowing policy.

The staff team and home had been recognised in a number of ways. The local authority had received positive comments from relatives which led to the home winning a ‘Pride in Medway’ award in 2013. Further positive comments had been received by the provider in 2014 which resulted in the staff team at Millstream House winning ‘team of the year’.

There were effective quality assurance systems and the registered manager carried out regular checks on the home to make sure people received a good service. A consultation and improvement plan had been developed to show actions that had been taken when shortfalls had been identified.

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