What life is like for people using this service:

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.

Mill House and Cottages is a residential care home for 44 people, some of whom may be living with dementia. The service also supports some people who have mental health support needs. This accommodation is provided in rooms within the main house on the site, and in 7 purpose built individual cottages. At the time of our inspection, 36 people were living at the service.

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

We carried out an unannounced comprehensive inspection of this service on 21 November 2014 and 16 January 2015. After that inspection we received concerns in relation to how people were being supported with drinks, specific risks to people’s safety and staffing levels. As a result we undertook a focused inspection on 9 November 2015 to look into those concerns. This report only covers our findings in relation to these topics. 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.

Mill House and Cottages provides residential care for up to 44 older people, some of whom may be living with dementia.

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.

We had recently received some concerns about this service and decided to carry out a focused inspection to see whether we could substantiate the concerns that had been raised with us. On the day of our inspection we were welcomed into the home. The senior on duty was busy with the medicines round so upon arrival we walked around the service, spoke with people living there, spoke with staff and observed general day to day tasks being carried out. The manager arrived later in the morning as they had covered the night shift.

We did not confirm the concerns that had been raised with us. People were being supported in a safe manner and received assistance to drink as necessary.

We found that the service was taking the necessary steps to ensure people who were at risk of falls had the risks to their safety reduced as far as was possible. People who were unable to use call bells were kept safe, but this required documenting as a risk assessment.

People who required support with drinks received this in a timely manner and were encouraged to drink. People who took their meals in bed were appropriately positioned to reduce the risk of swallowing difficulties.

There were enough staff to support people with their needs. This was kept under frequent review.

The ratings for all key questions and the overall rating of the service remain unchanged from our previous inspection of 21 November 2014 and 16 January 2015 when the service was rated ‘good’ throughout.

We left comment cards at the service during our inspection to allow people and their relatives to let us know their views about the service. None were completed or returned to us. During our visit we spoke to people who used the service including people with dementia, their visitors and the staff.

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.

People told us that they felt respected and involved by staff and that if they had any questions or concerns staff would be willing to address these. One person told us that, “The staff always have time to talk to me.” This showed us that people’s privacy, dignity and independence were respected. Each person had an individual care record including assessments of individual need and how these should be met by staff in the form of individual care plans to help to support health and personal care needs. This demonstrated to us that people experienced care, treatment and support that met their needs and protected their rights.

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.

We spoke with four people who lived in the service. They told us that their needs were met and that they were consulted about the care and support that they were provided with. People were complimentary about the staff that cared for them and told us that the staff always treated them with respect and that their privacy was respected. They told us that there were usually enough staff on duty but they sometimes had to wait for a staff member to assist them. They told us that they felt safe living in the home, that the environment was comfortable and clean and that they were provided with all the equipment they needed.

We spoke with four relatives. They told us that the staff and Manager made them feel welcomed and that they were good at keeping them informed of the changes needed to the care and support their relative received. They told us that staff members were kind, friendly and polite to people living in the home and themselves and that their relative was well cared for. They told us that there were usually enough staff on duty but their relative had to sometimes wait for help.

Four members of staff were spoken with and they told us that they had completed training. They told us that they talked to people living in the home and involved them in decision making about the care and support they received. They told us that they were given enough information about the changes made to the care and support of everyone living in the home and that the information held in the plans of care was good.

The Manager with whom we spoke told us that every effort was made to ensure that the needs of people living in the home were met and that staff members were fully trained. They told us that they would make improvements to the record keeping, serving of food system, environment and staffing levels to ensure people living in the home were well cared for and staff members safe.

Mill House and Cottages provides residential care for up to 44 older people, some of whom may be living with dementia.

The provider is required to have 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.

The home had a registered manager in post until May 2014. The provider initially had some difficulty appointing a suitable replacement manager but this was resolved in August 2014. At the time of this inspection, an experienced member of staff was employed as the acting manager and an application had been submitted for them to become the registered manager of the service.

This unannounced inspection was undertaken by one inspector on 21 November 2014 and 16 January 2015. At our previous inspection on 20 January 2014 we found that the provider was not compliant with all the regulations we inspected.

During our inspection on 20 January 2014, we found that care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

This was a breach of Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010.

At this inspection, on 21 November 2014 and 16 January 2015, we found that action had been taken to improve the way people’s individual care was planned and delivered and ensure their safety and welfare. We determined that there was no longer a breach of Regulation 9.

During our inspection on 20 January 2014, we found that the provider did not have an effective system to regularly assess and monitor the quality of service that people received, nor to identify, assess and manage risks in order to protect people from the risks of receiving care or treatment that was unsafe. This was a breach of Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010.

At this inspection, on 21 November 2014 and 16 January 2015, we found that improvements had been made to people’s risk assessments and that regular audits were being carried out in order to monitor the quality of the service and to identify and manage risks to people more effectively. We determined that there was no longer a breach of Regulation 10.

All the people we spoke with, who were living in the home, confirmed they felt safe living there. Relatives also told us that they had no concerns about their family members’ safety.

People’s care records that we looked at contained detailed risk assessments, which covered aspects of their daily lives, such as mobility, personal hygiene, nutrition and hydration.

Staff knew how to identify abuse and understood the reporting procedure, should they have any concerns that people may be experiencing any form of abuse.

Sufficient numbers of staff were on duty to support people, during both days of our inspection, and the provider was taking appropriate measures to recruit additional permanent staff, in order to fill the current vacancies.

Medicines were stored, managed and administered safely.

Although some areas of the premises were still in need of attention, significant improvements had been made by the provider to enhance people’s safety and wellbeing within the overall environment.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The DoLS are a code of practice to supplement the main Mental Capacity Act 2005 Code of Practice.

We were satisfied that applications for restrictions had been carried out appropriately and that the requirements of the DoLS were being met.

Staff received appropriate support, supervision and appraisals from senior staff or management. Staff also received regular training that was relevant to their roles.

People’s individual dietary needs were catered for and people were supported to eat and drink sufficient quantities.

Staff’s attitudes towards people living in the home were friendly, professional, caring and kind and staff were cheerful and enthusiastic in their roles.

People said that they could speak with the provider or any of the staff at any time and no-one had any cause for concern or complaints.

In addition to the acting manager, a regional director of the organisation visited the home on a regular basis and ‘on-call’ management was available by telephone, to provide any additional support that was needed.

Regular audits and reviews were being completed within the home, covering areas such as health and safety, medication, care plans, accidents, incidents, falls, pressure care, nutrition and hydration. These helped to ensure that service continued to operate well and that people’s needs were appropriately met.