The inspection took place on 9 July 2018 and was unannounced.

Milner 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.

Milner House is owned and operated by Care UK Community Partnerships Ltd. It provides accommodation and nursing care for up to 46 older people. People living at the service had a variety of medical and health care needs and some were also living with dementia. The service is laid out over two floors, although at the time of our inspection, the first floor was being refurbished and was therefore not in use. On the day of our inspection 18 people were living at the service, all of whom were accommodated on the ground floor.

We last carried out a comprehensive inspection of this service on 23 November 2017 when we rated the service as Inadequate and the service was placed in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is now out of special measures.

A new manager had recently been registered at Milner House. 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 registered manager had worked with a regional support team to deliver improvements across the service. Some work in respect of improving record keeping and refurbishing the environment was still ongoing, but it was clear progress was being made. We will continue to monitor the service and these areas will be followed up at our next inspection. Systems for auditing were now effective in developing quality within the service and the management team were committed to completing their own plan for improvement. A key priority for Milner House now will be stabilising the new staff team and ensuring people continue to receive a personalised service as the number of people accommodated increases.

The registered manager and staff had worked collaboratively to develop principles of person-centred care, empowerment and inclusion across the service. The result of this being that people now felt listened to and involved in the planning of their care. Staff took the time to engage with people in a kind and compassionate way and support was delivered in a personalised way that was no longer task led.

There was a relaxed and friendly atmosphere within the service and people enjoyed positive and caring relationships with staff. Support was provided with patience and empathy in a way that upheld people’s privacy and dignity. People now had opportunities to spend their time doing the things they enjoyed and that were meaningful to them.

People’s needs had been properly assessed and each person had a plan of care which enabled staff to deliver appropriate support. Staff were responsive to people’s changing needs and liaised with other health care professionals to ensure they received the care and treatment they required. People were supported to make informed decisions about their end of life care and medicines were managed safely and administered as prescribed.

There were now sufficient care and nursing staff to support people safely and in accordance with their needs. Staff received ongoing training and the clinical supervision of nursing staff kept them up to date with best practice.

There were systems in place to safeguard people from abuse and t

The inspection took place on 23 November 2017 and was unannounced. Our last inspection was in September 2016 where we found no breaches of the legal requirements, but we rated the service as Requires Improvement as recent improvements had not become embedded and sustained.

Milner 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.

Milner House accommodates up to 46 people across two floors, each of which have separate adapted facilities and some shared facilities. People living at the home had a variety of medical conditions and healthcare needs. Most of the people at the home were living with dementia. At the time of our inspection there were 24 people living at the home.

There was not a registered manager in post, one of the provider’s operational managers was in the process of registering with CQC at the time of inspection. 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.

People did not always receive their care safely. We observed two instances in which staff used inappropriate moving and handling techniques when supporting people. Prescribed equipment was not used which placed people at risk of injury. Where risks were identified, we found that staff were not always implementing plans to keep people safe.

Where incidents and accidents had occurred, the measures put in place to reduce the risk of them happening again were not always implemented robustly. There were not sufficient numbers of staff present to safely meet people’s needs. We observed that where people required supervision as a part of their risk management plans, staff were unable to provide this due to being busy elsewhere.

Care was not always delivered in a dignified way. Half of the people that we spoke with told us that they had encountered staff that appeared reluctant to provide support to them. People said this was a particular problem at night time and this impacted on their wellbeing significantly. There were high numbers of temporary agency staff employed at the home and they did not always know people’s needs well. People reported that staff did not take due care with their belongings and there weren’t effective systems in place to ensure people’s belongings returned from the laundry. The laundry lacked organisation and we found that linen was not stored in a way that guaranteed it would not become contaminated.

There was a lack of good practice in relation to infection control. Where infection control risks were known about one person’s medical condition, a plan was not recorded to guide staff on how to prevent cross-contamination. Staff were also observed failing to follow good practice when supporting this person. Areas of the home were not clean and systems to prevent cross-contamination were not implemented correctly.

People’s medicines were not always managed safely. Discrepancies in medicines records had been identified in an audit by the provider, but had not been addressed. We also found shortfalls in the way that medicines were stored and monitored. Nursing staff did not receive the clinical supervision that they needed and there was a lack of leadership at the home. Staff were not held to account for work that they completed and there was a lack of oversight from the provider.

People did not always receive person-centred care. Care plans contained person centred information, but we identified occasions where things that were important to people were not documented in their care plans. People told us that the activities they were offered did not cover

Milner House is a care home that is registered to provide nursing and residential care for a maximum of 76 people. The provider told us that the service no longer uses its capacity for double rooms and as such they would only accommodate a maximum of 46 people in single rooms. The provider is currently in the process of applying to reduce the maximum of number of people that the service can accommodate. There were 30 people living at Milner House at the time of our inspection, one of whom was in hospital and not available to speak with.

The service did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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. The previous registered manager had not been working in the service for a number of months and their registration has now been cancelled with us. The day to day management of the home was being undertaken by one of the operational support managers for Care UK who had been based at the service since February 2016.

We previously carried out an unannounced comprehensive inspection of this service on 8 and 9 February 2016. At that inspection we found a number of breaches of Regulations in respect of staffing, management, safeguarding, person centred care, nutrition and treating people with dignity and respect. As a result we issued six Requirement Actions for the service to improve. Following that inspection a number of further concerns were received about the way people had been treated by staff at Milner House. As a result we worked with the provider and our partner agencies to ensure people were safe. On 19 June 2016, we undertook a further focussed inspection to talk with people, their relatives and staff about the care people received. This inspection found that people felt happier at the service and that the provider had taken appropriate action to improve the service they received.

Since our comprehensive inspection in February 2016 we have continued to engage with the provider on a very regular basis. We asked the provider to submit regular action plans that updated us about the steps they had taken to improve the service. We also asked the provider to submit us copies of staffing information and provide assurances that safe staffing levels were maintained each week. This inspection confirmed that the provider had taken the action they told us they had. The service now had good systems in place for the monitoring and auditing of quality.

There has been a period of considerable change at Milner House this year. Whilst it was evident that the quality of care had significantly improved, the leadership of the home now needed to be embedded and sustained through the recruitment of a permanent management and staffing team. We identified that the provider lacked a clear vision about the type of service Milner House could provide moving forward. We have therefore recommended that the provider review the Statement of Purpose, taking into account the physical environment of the service as well as the skills and experience of the staff employed.

The provider had maintained safe staffing levels through the provision of agency staff. Considerable efforts had been made by the management team to ensure wherever possible the same agency staff were used and they were appropriately inducted to the service. Through the use of pen portraits, life stories and summary documents information about how to effectively support people was made available to staff who were less familiar with their needs. Whilst this was helping to provide a more consistent level of support for people, the lack of a permanent team of staff was still impacting on them.

The service had not recruited any new staff since our last inspecti

Milner House is a care home that is registered to provide nursing and residential care for a maximum of 76 people. The provider told us that the service no longer uses it’s capacity for double rooms and as such they would only accommodate a maximum of 46 people in single rooms. We have therefore requested that the provider submit an application to reduce the maximum of number of people the service can accommodate. There were 34 people living at Milner House at the time of our inspection, one of whom was in hospital and not available to speak with.

The service had a registered manager in post, although this person was not working at the service at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (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 carried out an unannounced comprehensive inspection of this service on 8 and 9 February 2016 where six breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the requirements in relation to those breaches.

Since that inspection we have received a number of concerns in relation to the way people had been treated by staff at Milner House. These concerns are currently being investigated through a large scale enquiry with our partner agencies. We have been in regular contact with the provider since our last inspection and they have been providing us with weekly updates against their action plan. We decided to undertake this inspection to ensure that the information we had been given by the provider was an accurate reflection of people’s experiences of the service.

This report only covers our findings from talking to people, their relatives and staff about the care people received. We did not look at any records and we did not follow up on any of the breaches previously identified as the provider has told us that they are still working on making the required improvement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Milner House on our website at www.cqc.org.uk.

Our last comprehensive inspection highlighted that some staff were not kind and showed a lack of respect towards people. At that time, staff did not always take adequate steps to protect people’s privacy and dignity.

Since our last inspection, the provider assigned a senior management team to oversee the running of Milner House and ensure improvements were made. A large number of agency staff have also been brought in to support the service. The provider identified steps they had taken through action plans to try and change the culture within the service and ensure people’s needs were met in a kind and caring way.

At this inspection, we found that the action taken by the provider had improved the way people received their care. Whilst people and relatives highlighted the difficulties attached to the use of a large number of different staff, people told us that they felt safer now. We observed lots of positive interactions between people and staff and the atmosphere in the service was significantly more relaxed and friendly. People said that staff were kinder to them and nobody told us that they felt scared.

The provider had made key information available to staff to ensure that people’s primary needs were met. The relatives of people who had higher needs told us that they had concerns that the attention to detail was lacking because staff did not know their family members. In particular, it was highlighted that some people were not always wearing their own clothes or the right glasses.

People’s privacy and dignity were better respected. Unlike at our previous inspection, staff routinely knocked on people’s door

Milner House is a care home that is registered to provide nursing and residential care people for a maximum of 76 people. The registered manager told us that the service no longer uses its capacity for double rooms and as such they would only accommodate a maximum of 46 people. There were 40 people living at the home at the time of inspection.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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 identified multiple concerns with regard to the way services were being provided at Milner House. The registered manager did not have sufficient oversight over the running of the home. Her management style was reactive and people often experienced care that did not meet their needs or expectations.

Staffing levels were insufficient and did not match people’s high levels of dependency. We found that some people had to wait too long for their care which left them feeling vulnerable and scared. Staff morale was low because some staff were frustrated that their repeated requests for additional care support was not actioned. People did not receive person centred care and felt that some staff were unkind to them as they provided support in a hurried and rushed manner.

The registered manager had not recognised that some of the concerns that people raised amounted to allegations of emotional abuse and neglect. We therefore had to direct the registered manager towards taking appropriate action to safeguard people.

People had been placed at risk because the controls in place to reduce exposure to Legionella had not been managed effectively. The registered manager had not taken appropriate steps to ensure that immediate risks were minimised and a long term solution sought to prevent reoccurrence.

Whilst most people had a choice about their food, the serving of meals was task orientated and not personalised to people’s individual routines. Specialist dietary needs and preferences were not always met because staff did not fully understand the needs of the people they supported.

The service had a programme of staff training, but closer supervision of staff was needed to ensure that learning was reflected in practice. Whilst staff knew the need to gain consent from people they lacked a good understanding about what to do if a person lacked the capacity to make a decision for themselves. Staff were also unaware of the people for whom the registered manager had assessed as potentially being deprived of their liberty which meant their care may not have been provided in the least restrictive way.

Some staff showed a lack of respect for people and their home. For example we saw that some staff did not respect people’s privacy by knocking on their bedroom doors before entering. We saw some genuine acts of compassion from staff, but not all staff had positive relationships with the people they supported.

People were not adequately supported to participate in activities that were meaningful to them. As such, most people spent the majority of their day either asleep or sat in wheelchairs. Staff were not always skilled at engaging with people, especially those living with dementia, effectively.

Formal complaints were investigated and resolved. There were limited opportunities however for people who felt nervous or were unable to raise concerns independently to express the things they felt unhappy about. These people did not feel listened to and valued.

Recent improvements to care planning meant that people’s physical needs were better assessed and monitored. Assessments however had not always been effectively transferred into robust guidelines for staff. Some staff were unfamiliar with recorded information an

During our visit to Milner House we spoke with seven people, seven relatives and five members of staff as well as the registered manager. We were not able to carry out formal interviews with all of the residents because of their mental capacity, however we were able to spend time observing how the residents interacted with staff.

From the observations that we made the people who used the service were comfortable and happy in Milner House. We saw relatives and people sitting together socialising and staff interacted with them in a kind and respectful manner.

We talked to the chef on the day of our inspection and observed people being served their lunch. When we asked opinions on the quality of the food we were told by one relative who visited each day “Excellent food.”

We looked at the staffing rotas during our inspection and talked to people about staffing levels on a daily basis. We received a mixed response from everyone we spoke to. For example some staff told us they felt there was enough staff and others felt under pressure and rushed.

The provider had ensured that they made people aware of how to make a complaint should they need to. All of the people that we spoke to on the day told us they had never felt the need to make a complaint.

We spoke to nine people who used the service or their friends and relatives who were visiting. All people that we spoke with were very positive about the care that they received or were receiving. When asked about the care they received from the staff one person told us “I like living here the staff are extremely kind.” Another person told us “There is a good rapport between us and the staff. We like it here.”

All people told us they were offered choices in their daily lives. We were told that staff are always talking to them and explaining things to them. We were told staff would go out of their way to be helpful and friendly.

People confirmed they felt safe living at the home. One person told us “it’s too safe as I am no longer allowed access to the balcony in my room.” This was discussed with the manager who explained this could be opened during the day.

We looked at training records for staff. We found that staff had been provided with a variety of courses to enable them to meet the needs of the people they were caring for.

Activities are provided daily and people who used the service said how much they enjoyed them. One person told us “I choose what I do there is no pressure to attend” and another told us “bingo is my favourite.”

This inspection took place on the14 and 16 January 2015. The first visit was unannounced.

We last inspected on 20 November 2013 where no concerns were identified

People told us they felt safe. Relatives told us they felt their family member was safe. They also told us the staff were kind, knew their relatives needs well and there was a nice happy atmosphere at the home.

People were supported in a way that promoted their dignity by being spoken to kindly and being supported with care discreetly. Staff were caring in their approach to people, giving them attention and not rushing them with support. Staff knew people well and clearly understood their individual needs and preferences.

The provider had systems in place to make sure people were protected from abuse and avoidable harm Staff had appropriate safeguarding training and knew how to report concerns.

Assessments were undertaken to identify people’s health and support needs and any risks to people. Plans were in place to reduce the risks identified in assessments. Care plans were developed with people to identify how they wished to be supported and these were regularly reviewed and updated.

People were supported by enough suitably qualified, skilled and experienced staff. Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

People were provided with a choice of healthy food and drink to make sure their nutritional needs were met. People and some of their relatives that ate at the home all said the food was good and they enjoyed it.

People and their relatives were involved and consulted about all aspects of the service including what improvements they would like to see.

There was a complaints process available. Relatives all said they never had any formal complaints but they knew how to complain if they needed to. One person told us if they were not happy they always spoke to the person involved first but if that didn’t work they could always talk to the manger. A relative told us people are encouraged to ‘speak up’ here.

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 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty these have been authorised by the local authority as being required to protect the person from harm. We found the home to be meeting the requirements of DoLS and the Mental Capacity Act 2005.