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. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 13 people in one adapted building. At the time of our inspection nine people were living at the home.

We checked to see if the care service had been developed and designed in line with the values that underpin ‘Registering the Right Support’ and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service should be able to live as ordinary a life as any citizen. The registered manager was committed to developing the person-centred culture of the service. However, they were not familiar with this guidance.

At our previous inspection in June 2017 we rated the service as ‘requires improvement’. At this inspection we found the service continued to be rated ‘requires improvement’. This was because, although the service had made improvements since the last inspection some work was still required in relation to end of life care, how records were kept and how quality was monitored.

This unannounced inspection took place on 24 May 2018.

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.

People felt safe living at the service, with the staff and with the support the staff gave them. People were protected as far as possible from abuse and avoidable harm by staff who were trained and competent to recognise and report abuse.

Medicines were administered safely and people were supported to access health and social care services when required.

The provider had effective recruitment processes in place and there were sufficient staff to support people safely.

Staff understood their roles and responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff gained people’s consent before they provided any care or support to them.

People had enough to eat and drink and menus appeared to offer a balanced diet. People’s choice, preferences and involvement in preparing meals were promoted, although some people chose to not participate.

People were supported to have choice and control of their lives and there were risk assessments in place that gave guidance to staff on how risks to people could be minimised without compromising their independence.

Staff supervision was provided regularly and training to enable staff to support people well was all up to date.

Staff were kind and respectful to people and we saw some positive interactions during the inspection. People were supported to pursue their interests.

Care plans took account of people’s individual needs, preferences, and choices and were reviewed regularly although end of life planning was not included. A system was developed immediately following the inspection to address this for the future.

A system to log complaints and outcomes was not in place so it was not possible to review whether or not they were managed effectively, or how they were used to make improvements to the service.

The provider had clear values to underpin the service that were known and understood by staff. The registered manager promoted a person-centred culture within the service.

The provider had a quality monitoring processes in place to monitor the standard of care but this was not sufficiently detailed to demonstrate that a full overview was carried out. Following the inspection, the registered manager

Milton House is located within a residential area of Bedford and provides accommodation and personal care for up to 13 people. They care for people who have a learning disability and support them with activities of daily living and accessing the community. On the day of our inspection there were 10 people living at the service.

The inspection was carried out on 14 June 2017. At our previous inspection on 10 June 2015 they were rated good.

The service had a registered manager. 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.

Statutory notifications were not always sent to the CQC, as per the legal requirements of the service's registration. Some notifications, such as for safeguarding incidents, had been sent however; the provider had failed to notify us when Deprivation of Liberty Safeguards (DoLS) authorisations had been received.

In addition, we found that there not robust systems in place to assess, monitor and improve the quality of the care which people received which meant that the provider could not be assured that they were driving improvement

Some areas of the service did not provide people with a homely and welcoming environment in which to spend their time or receive visitors. We also found that there was a lack of evidence to show how people were involved in planning or making decisions about their own care.

Staff members sought people's consent and followed the principles of the Mental Capacity Act 2005 (MCA) when they lacked the capacity to consent. However; the systems in place to record people's consent, and the use of the MCA, were not always robustly followed.

People felt safe at the service. Staff members had been trained in safeguarding and the different types of abuse and they knew the procedure to record and report concerns. Incidents and accidents were also reported and there were systems in place to assess and act on risk. Staffing levels were sufficient to meet people's needs and recruitment checks were carried out when new staff were employed. Where necessary, the service supported people to take their medicines safely.

Staff members received training and supervision which helped to ensure they had the skills they needed to meet people's needs.. People were supported to ensure their nutritional needs were being met and to have access to healthcare professionals as necessary.

People were treated with privacy, dignity and respect. Staff members worked to ensure that people's care was person-centred and based on their individual needs and preferences. The service promoted people's independence and supported them to take part in the chosen activities and people regularly accessed the local community. Feedback was welcomed by the service, including complaints, although work was needed to develop the way this was recorded.

The service had a positive ethos and culture. Staff members worked hard to ensure people's needs were met and were motivated to perform their roles. People and staff knew who the registered manager was and felt well supported by them.

We found that the provider was in breach of legal requirements. You can see what action we told the provider to take at the back of the full version of the report.

Milton House is a residential service providing care and support for up to 13 people with a learning disability. At the time of our inspection, there were seven people using the service. Milton House is situated in a residential area of Bedford, close to the town centre.

The inspection was unannounced and took place on 10 June 2015.

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.

Prior to our inspection we received some information of concern that alleged the service had poor staffing levels, which impacted upon staff’s ability to keep people safe. We also received concerns that the systems and processes in place for assessing people’s mental capacity were not rigorous.

During this inspection, we found there were sufficient staff members on duty, with the correct skill mix, to support people with their required care needs. People’s consent to care and treatment was sought in line with current legislation and where people’s liberty was deprived; best interest assessments had taken place.

Staff had regular supervision meetings with the registered manager to support them with training and development needs. We discussed with the registered manager and provider about alternative methods of capturing the information forthcoming from these sessions.

People’s needs were reviewed regularly to ensure that the care they received was relevant to them. Improvements were being made to the care planning systems in place, to ensure that records were more person centred for the people who used the service.

Quality assurance systems were in place and were used to obtain feedback, monitor performance and manage risks. Some formal analysis of the outcome of satisfaction questionnaires had been undertaken to ensure that people’s feedback was acted on.

People felt safe within the service. Staff knew how to identify potential abuse, and were aware of how to respond to allegations of abuse to keep people safe.

Risks to people’s safety, both within the service and in the wider community, had been assessed and were detailed clearly within people’s care plans.

The recruitment process was appropriate and ensured that suitable staff were employed to look after people safely.

The systems in place in respect of medication administration, disposal, handling and recording helped to keep people safe.

New staff underwent an induction programme, which prepared them appropriately for their role.

Staff were also provided with a range of training to help them keep their skills and knowledge up to date.

People received a balanced diet, and were provided with an adequate amount of food and drinks of their choice.

People were supported to see healthcare professionals as and when they needed to ensure that their healthcare needs were met.

The staff that supported people were caring, and promoted their privacy and dignity. People were supported to take part in activities of their choice.

The registered manager investigated and responded to people’s complaints in accordance with the provider’s complaints procedure.

We considered all the evidence we had gathered under the outcomes we had inspected to answer questions we always ask; Is the service Caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well lead?

This is a summary of what we found-

Is the service caring?

We saw that staff showed patience when supporting people and encouraged independence. One person we spoke with said, “They (the staff) are all very good, they look after us well”

Is the service responsive?

People were being appropriately referred for assessment and treatment by other health and social care professionals. People were assisted to enjoy activities of their choice with support where required.

Is the service safe?

People were treated with dignity and respect by staff. People’s needs had been assessed on admission to the home and risk assessments were in place.

Is the service effective?

People’s health and care needs were assessed, and care plans written to reflect individual people’s needs. People were involved in the planning of their care and signed to consent to this. There was an advocacy service available if people needed it, this meant that when people required additional support it was available.

Is the service well lead?

Quality assurance processes were in place to ensure people received a quality service. One staff member we spoke with told us “The service users are lovely, the manager has made some changes, but for the better”.