Mildenhall Lodge provides accommodation, nursing and personal care for up to 60 older people. There were 51 people living in the home on the day of our inspection. This inspection took place on 15 November 2017 and was unannounced.

Mildenhall Lodge 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.

Mildenhall Lodge accommodates people across four separate units, each of which has separate adapted facilities. Two of the units specialises in providing care to people living with dementia, one unit is residential care and the fourth for people who have nursing care support needs.

At our last inspection on 3 February 2016 we rated the service ‘Good’. At this inspection we found significant improvements. People continued to receive a very good level of care and further developments had been made under’ responsive’ and ‘well-led’. We have rated the service ‘Outstanding’ in ‘responsive’ and ‘well-led’ and therefore overall.

There was a registered manager in post at the time of our 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.

The service was extremely well managed by an accomplished, knowledgeable and highly motivated registered manager. There was lots of highly positive feedback about the home and caring nature of staff from people and relatives. The registered manager and staff were proud of where they worked and committed to delivering a high standard of care.

The registered manager had a clear vision and through a very comprehensive and detailed audit programme continually reviewed, assessed and monitored the home. A strong emphasis was placed on continually improving and further developing the home in response to and based on people’s feedback.

The home was exceptionally responsive to people’s individual needs and placed people at the heart of their care. Staffs’ potential to deliver additional tasks such as dementia audits was recognised and promoted by the registered manager. Activities were planned by staff who worked to ensure that all people were able to be involved. People were supported to take part in activities of their choosing.

Staff understood the importance of safeguarding people from the risk of abuse and knew how to report any concerns. Risks to people's health, safety and wellbeing had been assessed and plans were in place to minimise any identified risks to keep people safe from the risks of harm or injury.

People were supported by staff who were trained and who received support from a manager. Staff felt valued and enjoyed working at the home. There were enough suitably trained staff to help keep people safe and to meet people's needs. Staff received the training and support they needed to meet people's needs effectively. Staff felt well supported by management and felt able to speak with senior staff at any time.

Care plans were personalised to reflect people's personal preferences. People were supported to maintain a balanced diet, which they enjoyed. Health and social care professionals were regularly involved in people's care to ensure they received the care and treatment which was right for them.

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 caring and treated people with respect. Staff knew people's likes and dislikes which helped them provide individualised care for people.

The inspection took place on the 3 February 2016 and was unannounced.

The service is registered for up to 60 older people who may require residential, nursing or dementia care. There were 40 people at the home on the day of our inspection and one of the units has not opened since the home first opened. There was a newly 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.’

The home had an unannounced, comprehensive inspection on the 17 and 22 December 2014. The home was given a rating of requires improvement in every key line of enquiry we inspect against. We also identified a number of breaches of legislation for: medication, records and staffing. During our inspection on the 3 February 2016 we saw considerable improvements but still consider the service has not done enough in terms of ensuring the home is adequately staffed at all times, staff are suitably deployed and staff have the necessary skills and experience. For all other areas inspected we considered them good.

Feedback about staffing levels and our observations on the day confirmed that people did not always get their needs met in a timely way as some staff were not yet fully familiar with people’s needs, there was ineffective redeployment of staff at times and not all staff were working cohesively.

However people felt the care they received was good and risks to people’s safety were carefully monitored. Staff knew what actions to take if they observed or if people told them they were unsafe.

People received their medicines safely and at the correct time.

Staff recruitment processes were robust and vacant posts had been filled which should help improve the continuity of care.

Gaps in staff training and frequency of supervision were being addressed and staff felt well supported. Staff were accessing the appropriate training and able to demonstrate their knowledge. Some staff’s knowledge on the Mental Capacity Act was not sufficiently robust. However the manager and senior staff had a good knowledge. The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. The Deprivation of Liberty Safeguards (DoLS) ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation.

People were supported to eat and drink sufficient to their needs but the timeliness of this support varied according to the different units. Staff monitored what people ate and drank to make sure it was sufficient to their needs and did not place them at risk of dehydration or malnutrition. Records had improved but did not always accurately reflect what people ate and drank.

People’s health care needs were understood by staff and monitored closely so staff could respond to a change in a persons need or risk.

People’s care needs were clearly documented and kept under review so they reflected the person’s current needs.

There were planned activities to help keep people mentally stimulated and evidence was provided that people were consulted about which activities they would like to do.

There was a robust complaints procedure and opportunity for people to raise concerns/improvements they would like to see.

Staff were caring and helped to promote people’s independence and dignity.

The home was well led and improvements had been identified since the last inspection.

The home had adequate quality assurance processes which helped the manager determine what was working well and what required improvement. There was strong leadership and staff felt

We last inspected this service on 31 July 2014 and found that people’s needs were not being met and that poor care practices had placed people at risk. We had particular concerns about the care for people who had a diagnosis of dementia and those with diabetes. We took enforcement action which required the service to improve the way it provided care and support to people and gave a deadline for them to achieve this. The service submitted an action plan to us which outlined how they would ensure the required improvements were made. We returned at this inspection to check that improvements which related to people’s care and welfare had been made. At this inspection we found that there was evidence of some improvement to comply with the warning notice we had issued but some concerns still remained.

Before our inspection we also received information of concern regarding how the service managed people’s medicines. We followed this up to make sure that people received medication safely and in a way that met their needs.

During our inspection we spoke with four people who used the service, eight relatives, eleven members of staff, the support manager and the regional manager. We carried out a structured observation and observed staff providing care and support on two of the units, including the nursing unit. One unit was closed to visitors as a part of an infection control procedure and so we did not inspect there. We also looked at the care records for five people. Other records we reviewed included staff files, medication records and quality and monitoring records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

We found that medicines were being managed in a way that kept people safe. Care plans for people with diabetes had been improved and staff were more knowledgeable about caring for people with this condition. We were concerned that low staffing numbers and the use of agency staff who were not familiar with people's needs placed them at potential risk.

Is the service effective?

We found improvements had been made with regard to the care plans for people with diabetes and the completion of food and fluid charts, although some people were still not reaching the agreed target set for fluid intake. We were concerned that there was still little in the way of leisure opportunities for people. We were also concerned that the numbers of staff on the nursing unit, and at times on the dementia unit, did not meet people’s needs. The needs of people who used the service were documented in their care plans but sometimes information was not easy for staff to locate and did not contain all the information they needed to support people effectively.

Is the service caring?

People we spoke with told us they were happy with the care they received. One person told us, "They look after me excellently - everybody's very nice". Relatives told us that although they had concerns about the numbers of staff they found the staff to be kind and very caring.

Is the service responsive?

People who used the service and their relatives told us they sometimes had to wait a long time for staff to help them with personal care. We found that the service did not always update people’s care plans promptly when there had been a change in their needs.

Is the service well led?

It was clear that the management of the service had made improvements with regard to the monitoring and auditing of care plans and medication. We remained concerned about the lack of management strategy to address the lack of staff at critical times.

During our inspection we spoke with eight people who used the service, three relatives, seven members of staff and the registered manager. We carried out a structured observation and observed staff providing care and support on all three units. Other records we reviewed included staff files and quality and monitoring records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

Care records were not always updated to ensure that people received the care they needed to keep them safe. We found some records which were not completed appropriately and contained conflicting information which placed people at risk. Some records were not sufficiently detailed to ensure that staff had all the information they needed to keep people safe.

The service worked with other healthcare professionals to help meet people’s healthcare needs.

We saw that regular checks were carried out on the fire equipment and systems. However we found that the call bell system was not operating correctly throughout the service and this posed a risk to people who used the service.

We observed how staff provided care and support and looked at staffing rotas. We found that there were not always enough trained and experienced staff on duty to meet people’s needs and ensure their safety.

We found that the service was aware of their responsibilities under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and most staff had received training. We saw that the service had made a DoLS application for one person and was considering making two further applications. This meant that the service was taking steps to ensure that people were kept safe and not unlawfully deprived of their liberty.

Is the service effective?

People’s care and support needs were assessed in consultation with either the person themselves or relatives. Most people’s care plans reflected their care and support needs although we found that some plans did not identify in enough detail how their needs should be met.

We found that care plans to monitor and manage people’s diabetes were not specific and management of people’s diabetes was not effective.

We were concerned that a lot of people seemed to be spending the majority of their time in their rooms. One person told us, “There’s not much to do. The food is very good. I eat my meals in my room”.

Is the service caring?

People were supported by staff who were caring and respectful. We observed staff engaging positively and warmly with people.

People who used the service and their relatives told us that they found the staff very caring. One person told us, “I wasn’t feeling very well yesterday and they looked after me lovely”. Another person said, “[My relative] likes to look after [their] appearance. I find [they] always look nice”.

Is the service responsive?

Low staffing levels on the day of our inspection meant that people did not always get the help and support they needed promptly. People who used the service told us that although they were happy with the staff they struggled to find them at times. One person who used the service told us, “The staff work hard but you have to be patient. It does take them some time to answer your call bell”. We found that call bells were not always answered promptly.

Records showed that where concerns about an individual’s wellbeing had been identified, staff had not always taken appropriate action to ensure that people were provided with the support they needed.

Is the service well led?

We were concerned that despite the fact that the service had only been operating for a number of weeks we were able to identify a number of issues which required improvement.

Systems to assess staffing levels and review and monitor care plans were not robust. We were concerned that the service had not identified yet how to audit the response times to the call bells. When they did learn how to gather this information following a request from us it highlighted that some call bells had not been answered within an acceptable timeframe.

The inspection took place on 17 and 22 December 2014 and was unannounced. The inspection visit on 22 December was undertaken during the evening.

The service was last inspected on 31 July 2014 when it was found to be in breach of a number of regulations which relate to people’s care and welfare, quality assurance, record keeping and staffing. We asked the service to take urgent action to improve the care and welfare for people and we checked this at an inspection carried out on 26 September 2014. We found that improvements had been made but we still remained concerned about some aspects of people’s care and welfare and so we set a compliance action and asked the provider to send us an action plan outlining how they intended to continue to improve.

At this inspection we checked to see if the service had carried out the required actions to bring about improvements in the service. We found that there was evidence of improvement but that some further improvements were required

The service provides accommodation and nursing care for up to 60 people, some of whom are living with dementia. At the time of our inspection there were 27 people resident. The service is divided into four almost identical wings. Only three were being used and each unit led on to a communal area with a café and other communal facilities.

The service has had a number of managers since it opened in June 2014 but has not had a registered manager in post since September 2014. 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 current manager is temporary and will remain in post until a permanent manager is appointed.

We found that staffing levels meant that sometimes people were left without the staff support they needed.

Medicines were managed well for most people but we were concerned that some errors had not been noticed or investigated by staff. We also found that medicines were being given to people later than their prescribed times which could have placed people at risk.

Staff were trained in safeguarding people from abuse. We found that some potentially harmful substances were accessible to people living with dementia. Other risks were assessed and action taken to reduce the risks to the people who used the service. The recruitment process included checks which aimed to make sure that staff could be employed without posing a risk to people.

Staff received the training they needed to carry out their roles and new staff received an induction. Some staff demonstrated an in depth knowledge of the people they were supporting and caring for while others did not.

We saw that staff demonstrated that they understood the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards DoLS) and acted in accordance with them. The MCA ensures that, where people lack capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation.

People who used the service were very positive about the food and were able to exercise choice about their meals. Special diets were well catered for but we some people did not get the support or prompting they needed to eat their meals. People identified as being at risk of not eating enough were promptly referred to the dietician and monitored. People were also supported to access other healthcare professionals when they needed them.

We found the majority of staff to be caring and committed. People were treated respectfully but people were not always encouraged to be independent or involved in the daily life of the service. People, and their relatives, were unhappy with the lack of things to do and were not supported to follow their own interests and hobbies..

People, or their relatives, were involved in assessing and planning care and had opportunities to meet with staff and review progress.

Formal complaints were managed well but some people found the response to concerns which were raised informally less so

The manager had begun to try to change the culture of the service and had introduced some new initiatives and had improved communication. People were confused due to the large amount of changes in management since the service opened. Most of the people who used the service did not know who the new manager was and had not had formal opportunities to meet with her. Quality assurance systems had not picked up some of the concerns we found on inspection.

We found continued breaches of regulations which relate to record keeping and staffing, as well as a breach of regulation which concerns the management of medicines. You can see what action we have told the provider to take at the back of this report.