Milverton Road

What inspectors found

From the Care Quality Commission's assessment published 18 February 2025 (assessment visit 19 November 2024). Quoted under the Open Government Licence.

1. Safe

   –No rating No rating

   Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. Based on the findings of this assessment the rating for this key question has changed from good to requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed.

   This was because we found concerns with medicines management. These failures had placed people at risk of harm under 1 breach of Regulations. Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

   We discussed concerns relating to medicine management and governance with managers and requested for some immediate assurances. They were able to provide some additional evidence of how outstanding issues had now been met.

   You can find more details of our concerns in the evidence category findings below.

2. Effective

   GGood Good

   Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life. We looked at 2 quality statements. For the quality statements not inspected, we used the scores awarded at the last inspection to calculate this key question rating. The rating remains good.

3. Caring

   GGood Good

   Caring – this means we looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect. At our last inspection we rated this key question good. At this assessment, we looked at 2 quality statements. For the quality statements not inspected, we used the scores awarded at the last inspection to calculate the key questions rating. The rating remains good. This meant people were supported and treated with dignity and respect. People always had enough to eat and drink to stay healthy. People were treated with kindness and compassion. Staff protected their privacy and dignity. Staff spoke positively about the people they supported. Staff ensured they communicated and shared information with people in a way they could easily understand and always respected the informed choices they made. People were encouraged to maintain relationships with family and friends.

4. Responsive

   GGood Good

   Responsive – this means we looked for evidence that the service met people’s needs. At this assessment, we looked at 1 quality statement. For the quality statements not inspected, we used the scores awarded at the last inspection to calculate the key questions rating. The rating remains good.

5. Well-led

   –No rating No rating

   Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At this assessment, we looked at 3 quality statements. For the quality statements not inspected, we used the scores awarded at the last inspection to calculate the key questions rating. Based on the findings of this assessment the rating for this key question has changed from good to requires improvement. This was because we found concerns with the effectiveness of how the service operated their governance systems and responded to issues found. The service experienced a drop in staffing levels. This lack of stable staffing has negatively impacted on the services culture and ability to operate their monitoring systems effectively. These failures had placed people at risk of harm under 1 breach of Regulations. Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.