Mill House & Cottages

Mill House and Cottages is a residential care home providing accommodation and personal care to 23 people aged 65 and over at the time of the inspection, some of whom are living with dementia. The service can accommodate up to 44 people in two areas within the main building and has nine bungalows adjoining this for people who wish to have an environment that better promotes their independence.

People’s experience of using this service and what we found

The last rating for this service was inadequate (published 30 March 2020) and there were multiple breaches of regulation. Following this previous inspection a warning notice was issued by CQC in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding the safe management of people medicines and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and imbedded by the service and the provider was no longer in breach of regulations and the warning notices had now been met.

The premises were maintained to a good standard. Extensive refurbishment had taken place to improve the internal and external surroundings, maintaining the safety of those who reside within the setting.

The management of medicines had improved since our last inspection. Care plans in relation to covert medicines and as and when required (PRN) medicines had been reviewed to ensure people received their medicines in a safe and personalised way.

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

Staff supported people in a confident, competent manner. Training and development had improved since our last visit, enabling staff to develop skills to improve the support offered.

People were well supported at mealtimes. Staff engaged positively at these times and ensured people were given choice, appropriate equipment and support to enjoy their meal. People told us they enjoyed the food offered. One relative told us, “There is a fruit bowl and biscuits, if you need a snack and the cook is very good. Proper food”.

Staff were kind, caring and promoted people’s dignity. Staff understood the importance of treating people with respect and ensured they did this. People were observed to have good relationships with the staff team.

Care plans and risk assessments had been personalised and gave clear direction for staff to follow. These documents had been regularly reviewed and gave an accurate representation of individuals support needs and wishes. People were able to engage in activities and staff made time to engage and interact. Complaints were responded to quickly, and learning used to improve the quality of service.

The provider and manager had implemented a comprehensive service improvement plan, people and their relatives told us that the service had improved greatly. The manager provided staff with leadership and was visible and approachable, with a hands-on approach to modelling best practice working alongside staff supporting people. Staff were motivated and enjoyed strong team work, they commented to us positively on improvements made.

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

This service has been in Special Measures since 30 March 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from inadequate to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mill House and Cottages on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Mill House and Cottages is a residential care home providing accommodation and personal care to 25 people aged 65 and over at the time of the inspection. The service accommodates people in two areas within the main building and has six bungalows adjoining this for people who wish to have an environment that better promotes their independence.

People’s experience of using this service and what we found

Risks to people's safety had not been adequately assessed or reviewed. We identified that equipment was in use that should have been removed from service due to safety issues. People were not protected in a safe environment. The premises were not maintained to a standard which ensured people were safe. We identified risks in the environment which had not been recognised or addressed by staff or the management.

The management of medicines had not improved since our last inspection and we found improvements were still required in record keeping, ensuring safe application of medicine patches and administration of covert medicines. People did not always receive their medicines on time.

There were widespread shortfalls in the training of staff to ensure they had the skills, competence and experience to provide good quality care and keep people safe. The mealtime experience for people was poor, staff did not promote choice to aid people’s enjoyment. The provision of meals for people who needed the texture of them to be adapted was poor. Where people lacked the capacity to make decisions, detailed assessments of this had been carried out and best interest decision made in line with the law. A major refurbishment of the premises was underway to improve the environment and better meet the needs of people living with dementia.

We have made a recommendation the provider ensures catering staff complete training in the preparation of food for people who swallowing difficulties.

Staff did not always promote people's dignity to ensure their right to privacy was upheld. Improvements were needed to ensure all people were able to be as independent as possible. People were not always involved in all aspects of their care planning. Staff were kind hearted but were task focused in their support and did not always take the time to listen to people.

Stimulation, activities and opportunities to reduce the risks of social isolation needed improvement. People received minimal interaction from staff because they did not have the time or resources to provide this. Complaints records were unable to be located, however people, their relatives and visitors were clear who they could raise a concern to.

There was a lack of clear governance in the service and the provider did not have effective systems in place consistently assess, monitor and improve the quality of care. This meant poor care was not identified and rectified by the provider. There had been an exceptionally high turnover of managers providing leadership to the service. Our two previous inspections have rated the service as Requires Improvement and the service is now rated Inadequate. We are therefore concerned about the overall governance of the service.

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

Rating at last inspection and update: The last rating for this service was requires improvement (Published 25 July 2019) and there were multiple repeated breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. This is the third consecutive inspection the service has been rated as requires improvement or inadequate, and we have found breaches of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to the management of risks to people, management of medicines, staff training and competency, nutrition and hydration and management, governance and quality of care in the service.

We have issued a warning notice to the provider in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

regarding the safe management of peoples medicines In additional to this, we have also issued a warning notice to the provider in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Mill House and Cottages is a residential care home providing accommodation and personal or nursing care to 31 people at the time of the inspection. Some people who use the service are living with dementia. The service can support up to 44 people. The service accommodates people in two areas within the main building and has six bungalows adjoining this for people who wish to have an environment that better promotes their independence.

People’s experience of using this service and what we found

People were not always supported to take their medicines in a safe way. Not all staff followed the providers systems for ensuring the administration of medicines. Infection prevention and control practices were not sufficient, and the home was unclean in places.

There were enough staff to keep people safe, however staff had become task focussed and did not have the time to spend with people to engage in conversation. The provider was in the process of recruiting additional staff but had very limited success and needed to review how it was going to address this. Staff had a good understanding of safeguarding practices and how to raise a concern. Risks to people had been clearly identified in care plans however staff did not record in detail the actions they had taken to meet peoples care needs or any interventions provided.

The service had received extensive support from the provider in order to address the concerns raised at our last inspection. Improvements had been made and we saw progress measured accurately against the providers action plan. However, the service still had shortfalls in the provision of good quality care. This was compounded by the providers ability to recruit high quality experienced staff. We found that there was a strong commitment from the providers representatives supporting the service to make improvements at the service. There was ongoing significant investment in improving the homes environment. The providers director services management team had acted with transparency and acted upon their duty of candour through out the inspection. The acting manager has started the process of registering with the Care Quality Commission.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 15 February 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We received concerns in relation to the management of medicines, staffing levels and good governance of the service. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-Led sections of this full report. The overall rating for the service has remained Requires Improvement. This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mill House and Cottages on our website at www.cqc.org.uk.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The quality of care provided, leadership and oversight of the home had deteriorated since our last inspection. The provider had recently begun to identify this and during our inspection took actions to address it.

People were not always supported to take their medicines in a safe way. Not all staff followed the providers systems for ensuring the administration of medicines which resulted in a significant error during the inspection.

There was enough staff on duty to keep people safe. Several staff had recently left which meant temporary staff supplied via an employment agency had been used. New staff had been recruited but were still in the process of becoming familiar to people. This had led to a period whereby people felt unsettled. Existing staff were working hard to support these new staff as they felt the manager was overwhelmed and did not have the time to do so.

Checks to ensure the environment was safe and clean had not been completed. We found areas which posed a risk to people because they had not been kept in good repair or regularly cleaned. Items which posed a risk to people such as cleaning equipment had not been kept securely.

Staff were kind and considerate to people, however during busy periods became task focussed and did not always ensure they were responsive to people’s needs. Staff ensured people’s privacy was maintained, and sought their consent before providing them with care.

Some people’s care records had not been updated since September 2018, where needs had changed, not all staff were aware of this. Staff had not always fully completed the daily records of people’s wellbeing. This had not been identified because the manager had not reviewed them as was required.

The provider’s systems to check the quality and safety of the service had not been undertaken by the manager since the departure of the previously registered manager in October 2018. We found that there had not been sufficient oversight of people’s day to day care, some actions to mitigate changes in people’s wellbeing had not been taken. The provider took immediate action to address this. A deterioration in communication between the manager and staff contributed to people not receiving the care they needed in some instances.

Staff understood the need to keep people safe and what was required to do this. Staff had received training in this area, and were clear they would report concerns to a manager or appropriate outside agency without delay.

More information is in Detailed Findings below:

Rating at last inspection: At the last inspection the service was rated Good (Report published 21 February 2018). At this inspection we changed the overall rating to Requires Improvement.

About the service: Mill House and Cottages is a residential care home that is registered to provide accommodation and personal or nursing care to a maximum of 44 people. At the time of our inspection, 34 people were living there.

Why we inspected: This inspection was carried out in response to incidents that had occurred in the service and concerns that had been raised about the safety, quality and management of the service.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve the rating of the service to at least Good. We will require them to provide an action plan detailing how this will be achieved. We will revisit the service in the future to check if improvements have been made.

Rating at last inspection

At the last inspection, the service was rated Good. At this inspection, we found the service remained Good.

Why the service is rated Good

People received support to take their medicines safely. Staff knew how to keep people safe from the risk of harm. Actions had been taken to reduce risks to people’s safety. There was enough staff to keep people safe and meet their needs.

Staff were competent to carry out their roles effectively and had received training that supported them to do so. People were supported to eat freshly prepared meals, and their individual dietary needs were met. People were able to access and receive healthcare, with support, if needed.

Although improvements had been made to the environment to help the people who lived there to orientate themselves around the service, some areas were in need of redecoration and refurbishment. Improvements had been made by the home’s management team to address this and an action plan put into place. Sufficient progress had been made, with a timescale for completion of the outstanding work to be done.

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 service supported this practice.

Staff were kind and compassionate in the way they delivered support to people. People were treated with dignity and respect. Staff ensured that people were able to have visitors, and enabled people to maintain relationships with relatives and friends who did not live nearby.

People and their relatives were confident that they could raise concerns if they needed to and that these would be addressed.

The registered manager ensured that the home was well run. Staff were committed to the welfare of people living in the home. The registered manager ensured they kept links within the local community and people were part of regular events.

Further information is in the detailed findings below

The people we spoke with and their relatives were mostly happy with the care provided. They felt involved and consulted. One person said, 'The staff are good. They explain things to me." A visitor told us they had been involved in decisions to refer their relative to the falls team for assessment.

There was mixed evidence about the quality of people's experience at the home. We observed that some members of staff interacted with people with dementia in a courteous and polite manner. We also observed that some staff did not understand how to do this in a way which supported the person with dementia and they responded to people in a way which was inappropriate to their age. Staff showed limited understanding of how to support people who were experiencing memory loss.

We saw that the links had been developed and maintained with providers of other services and that these mostly benefitted people who used the service.

There had been recent changes to the systems in place to audit the quality of the service. The information provided to us was not detailed enough to indicate there were effective processes in place to monitor the quality of the service and to identify, assess and manage risks to people with dementia.

Care plans for nutritional needs were in place and we noted that the service used the Malnutrition Universal Screening Tool (MUST) to assess those people who might be at risk of inadequate nutrition and hydration. This showed us that people were protected from the risks of inadequate nutrition and dehydration. We had a tour of the service and noted that the premises were clean and well maintained. This showed us that people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. We did not see people being kept waiting for assistance and staff spoken with demonstrated a good understanding of the needs of the people living in this service. This showed us that there were enough qualified, skilled and experienced staff to meet people's needs.