This inspection took place on the 9 and 10 January 2018. It was an unannounced visit to the service.

Milton 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.

Milton house accommodates 12 people in one adapted building. It is registered for people with epilepsy, learning and or physical disabilities. At the time of this inspection six people lived there.

The service 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.

At the previous inspection in January 2017 the provider was in breach of Regulation 18 of the Health and Social Care Act. 2008. This was because sufficient numbers of suitably qualified staff, competent, skilled and experienced staff were not consistently provided. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question safe and well-led to at least good. At this inspection we found systems had been put in place to ensure the minimum staffing levels were always maintained. However people’s needs had increased and changed since the previous inspection. As a result sufficient staff were not available at key times of the day to enable staff to safely meet people’s needs. The nominated individual immediately agreed to review the staffing levels and confirmed after the inspection that a third staff member would be rostered from 8am till 18:00 to provide an extra staff member at peak times. We have made a recommendation for the provider to keep the staffing levels under review in response to changes to people in line with best practice and dependency levels.

The people we spoke with and relatives were very happy with the care provided. Relatives commented “I am really grateful, I feel very lucky [person’s name] is there. I really can’t fault them.” Another relative commented “Staff have time for [person’s name} and they always show genuine concern and understanding. “

At this inspection the service was providing caring and responsive care. Improvements were required to ensure safe, effective and well- led care was maintained.

People were safeguarded from abuse but risks to people were not identified and managed. Staff were proactive in referring people on to the relevant professionals when people’s needs changed. However the service was slow to act on recommendations and advice from those professionals to promote a person’s safety.

Systems were in place to promote safe medicine administration. However the service failed to ensure they had an adequate supply of one person’s medicine and failed to seek medical advice to ensure the person’s health and well- being.

People consented to their care and staff worked to the principles of the Mental Capacity Act 2005. They were provided with information on how to make a complaint and this was reinforced to people at residents meetings.

People had care plans in place which outlined their needs and the support required. Their nutritional needs were identified and met. People had access to activities and keyworkers were looking at ways of developing more person centred activities in conjunction with the activities team.

The home was clean and homely. People were provided with equipment to promote their safety and independence. Systems were in place to ensure the environment was kept clean and prevent cross infection. The equipment provided was serviced and safe.

Staff had the required recruitment checks prior to commencing work at the service. They were inducted, traine

This inspection took place on 5 and 10 January 2017. It was an unannounced visit to the service. This meant the service did not know we were coming.

Milton house is a care home which provides accommodation and personal care for up to twelve people with epilepsy, learning and/or physical disabilities. At the time of our inspection there were seven people living in the home.

Milton house provides accommodation on the ground floor. The first floor is out of use.

A registered manager from another of the provider’s locations had recently taken on management of Milton house. They had applied to the Care Quality Commission to be the registered manager of Milton house as well as remain the registered manager for the other location. Their application to add Milton house to their registration was processed by the Commission on the 17 January 2017. 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 home was previously inspected in June 2016. At that inspection they were found to be in breach of three regulations and eight recommendations were made. They were rated as Inadequate in the Safe domain and received an overall Requires Improvement rating. This inspection was to follow up on progress with meeting the regulations and a review of their previous rating.

At this inspection we found improvements had been made. Regulations they were previously in breach of were now met. However, further improvements were still required to be made in relation to staffing levels, induction of staff and record keeping.

The service provided effective, caring and responsive care to people. People and their relatives were happy with the care provided. Relatives commented “Staff do a remarkable job and I can’t fault them. “We are all very happy, relieved and feel [person name] could not be in a better place”.

Improvements were required to keep people safe and to the management and monitoring of the service. This was because the staff worked over the expected amount of hours and the required staffing levels were not consistently maintained. Staff were suitably recruited, trained, supervised and supported. Staff who had been promoted into senior positions had not been inducted into their roles. This was immediately addressed but a recommendation has been made to ensure all staff are inducted into roles.

Systems were in place to safeguard people. Risks to people were identified and managed which promoted people’s independence and well- being. People had care plans in place which outlined the support required. Care plans were detailed, specific, updated and reviewed as people’s needs changed.

Medicines were safely managed. People had access to health professionals and their nutritional needs were met. People were involved with in- house activities and had access to activities on site and community based activities.

People’s privacy and dignity was promoted. Staff were kind, caring and committed to providing good care to people. They had a good relationship with people and were aware of their needs and risks. Staff communicated appropriately with people. They promoted people's choices and were responsive to them. Relatives described staff as approachable, kind, caring, warm, friendly, marvellous, pleasant, obliging and dedicated.

People and their relatives knew how to raise concerns or complaints. Resident meetings took place. This provided another opportunity for people to discuss issues that concerned them. People and their relatives were asked to feedback on the service annually. Quarterly relative meetings took place. This was a forum to keep relatives updated on the service and the organisation.

The provider had systems in place to audit th

This inspection took place on 14 and 15 June 2016. It was an unannounced visit to the service.

Milton House is a care home which provides accommodation and personal care for up to twelve people. At the time of our inspection eight people were living there.

Milton house provides accommodation on the ground floor. The first floor is out of use.

The service did not have 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.’ A manager had been appointed and was in the process of applying to the Commission to be the registered manager.

We previously inspected the service on the 4 February 2014. The service was assessed against five outcome areas at the time and found to be compliant.

At this inspection we found people’s medicines were not safely managed. Their care plans were not up to date and reflective of their current needs. Risks to people were not managed and put people at risk of injury. Staff were not working in line with the principles of the Mental Capacity Act 2005.

Staff were suitably inducted, trained but were not adequately supported and supervised in their roles. They were generally kind and caring but some staff practices did not promote people’s dignity and respect. Staffing levels had not been reviewed to take into account the change in people’s needs. Staff were not recruited in line with the organisations policy on recruitment and staff felt they lacked guidance and management support. People were asked to make choices and decisions on day to day care but aids and props were not routinely used to promote people’s involvement and communication. People’s records were not suitably maintained and fit for purpose. We have made recommendations to address these shortfalls.

The provider had systems in place to monitor the service but the auditing was not effective in picking up the issues and shortfalls we found.

People had access to a range of health professionals to meet their needs. They had individual programme of activities and some people were keen for the activities to be improved to promote more community based activities. People and their relatives knew how to raise a concern/ complaint and they were able to give feedback on the care and support provided.

People and their relatives were happy with the care provided. They described staff as being knowledgeable, kind, caring, committed and supportive.

The provider was in breach of three regulations and was not meeting the requirements of the law. You can see what action we told the provider to take at the back of the full version of the report.’

We looked at the personal care or treatment records of people who use services, carried out on a visit on 4th February 2014, observed how people were cared for and talked to staff and relatives. We looked at the action plan requested at the last inspection visit and observed changes made as a result of the plan.

We found staff treated the people with privacy and dignity and staff were encouraged to observe each other and share good practice. One relative told us, “The staff are warm and caring”.

People’s needs were assessed and care plans were clear and individualised, reflecting the needs of people who use services. Staff and the activity coordinator planned activities and people were taken out regularly.

One person told us, “The staff are always kind to me.”

A healthy balance and choice of food was offered using a new provider of ready-made meals, following an in-depth consultation, tasting and evaluation process. People were offered choice and meal times were managed to include all staff resulting in a calm, peaceful mealtime. Dietary needs were met and staff were properly trained in food hygiene. Specialist dietary advice was followed in the management of a person’s medical needs.

Suitable arrangements were in place to ensure that people were safeguarded against the risk of abuse. All staff had been trained in safeguarding adults and safeguarding was a regular training session at team meetings.

The home had assurances in place to assess and monitor the quality of services.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

People's privacy and independence were respected at the service. Care plans were person centred to reflect people's wishes and preferences. We saw risks were identified and measures put in place to reduce likelihood of injury or harm. People had

access to healthcare professionals to help keep them healthy and well. However people's diversity, values and human rights were not consistently respected or promoted.

The people we spoke with said that they were happy with the care and support they had received from the home. People decribed the quality of the care as "good" and "very good."

People who used the service told us that they felt safe and had not seen or suspected any cases of abuse. However we found people were not protected from the risk of abuse because staff lacked knowledge of the home's safeguarding policy and procedure. This meant people could not be assured if they were at risk of abuse staff would take the appropriate action.

People told us staff were able to deliver the right level of care and support. People told us “all the staff know us well here and understand our needs” and “staff are very good at their job.

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on.

People who use the service told us that they were involved in decisions which affected them which included meal choices, activities and holidays.

They told us that their privacy and dignity was respected and that staff call them by their preferred name. Staff did not always knock prior to entering their bedrooms. One person told us that they would like to get up a bit later in the mornings but can go to bed at a time convenient to them.

People who use the service told us that they are consulted on their care and treatment. They told us that they were well looked after and that they received good care.

They told us that volunteers had recently become involved with the home to provide friendships for them. They told us they had access to some leisure activities but not as much as they would like.

People told us that the food was very good and they were given enough to eat and drink. They told us they were given a choice of two meals each day at lunch time.

They knew who to speak to if they felt they were being badly treated by staff and knew how to make a compliant. They told us that monthly house meetings took place which enabled them to raise issues that concerned them.

People told us that they liked living at the home, they felt it was kept clean and well maintained.

They told us that staff give them their medication and that they get it at the required time. People told us that they thought the home could do with more staff at certain times of the day and should employ more male staff. They are not involved in interviewing staff

People told us that they were anxious about recent staff changes. The registered manager had left and a new manager was due to start at the home. They told us that the new manager had been visiting the home and getting to know them

People told us that they thought the regular staff were well trained. They also said that the staff that come in at short notice were not and did not know what to do.

Staff told us that they felt they were well trained and supported, with regular supervision taking place. A bank worker told us she had a brief induction into the home.