Mill Lane Nursing and Residential Home 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. Mill Lane Nursing and Residential Home accommodates up to 30 people requiring nursing care, and some living with dementia. During our comprehensive inspection on 21 January 2019, there were 25 people living in the service.

At our previous inspection of 14 July 2016, this service was rated Good overall, and in each of the key questions. At this inspection of 21 January 2019, we found the evidence continued to support the rating of Good overall. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns.

People continued to receive a safe service. There were systems in place designed to reduce the risks of abuse and avoidable harm. Where things went wrong, the service learned from this and used the learning to drive improvement. Risks to people continued to be managed well. People were supported with their medicines in a safe way. Staff were available to support people and the systems to recruit staff safely were robust. There were infection control procedures in place which reduced the risks of cross contamination.

People continued to receive an effective service. People were supported by staff who were trained and supported to meet their needs. People had access to health professionals when needed. Staff worked with other professionals involved in people’s care. People’s nutritional needs were assessed and met. The Mental Capacity Act 2005 was understood and complied with. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The environment was well maintained and suitable for the people using the service.

People continued to receive a caring service. People shared positive relationships with staff. People’s privacy, independence and dignity was respected. People were listened to in relation to their choices, and they and their relatives, where appropriate, were involved in their care planning.

People continued to receive a responsive service. There were systems in place to assess, plan and meet people’s individual needs and preferences. People’s had access to social activities to reduce the risks of isolation and boredom. There was a complaints procedure in place and people’s complaints were addressed. People’s end of life decisions were documented to reduce the risks of people’s preferences about how they wanted to be cared for at the end of their lives not being met.

People continued to receive a service which was well-led. The registered manager and provider had a programme of audits which demonstrated that they assessed and monitored the service. Where shortfalls were identified actions were taken to improve. People were asked for their views about the service and these were valued and listened to. As a result, the service continued to improve.

Mill Lane Nursing and Residential Home provides accommodation and nursing and personal care for up to 30 older people, some living with dementia.

There were 25 people living in the service when we inspected on 14 July 2016. This was an unannounced inspection.

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.

Our previous inspection of 20 July 2015 found that improvements were needed in areas including how people’s food and fluid was monitored, how staffing was calculated, and how the service monitored and assessed the service provided to people. The provider wrote to us and told us how they were addressing these shortfalls. During this inspection we found that improvements had been made.

Where concerns were identified about a person’s food intake, or ability to swallow, appropriate referrals had been made for specialist advice and support. This was recorded and acted upon. Monitoring of people’s food and fluid intake were undertaken to demonstrate that people had received what they needed to support their overall wellbeing.

Quality assurances systems had improved and the service had identified shortfalls and taken action to address them.

Staffing numbers were assessed against and reflected people’s dependency needs. Staff were trained and supported to meet people’s needs.

People, or their representatives, were involved in making decisions about their care and support. People’s care plans had been tailored to the individual and contained information about how they communicated and their ability to make decisions. Guidance for staff identified people’s specific care needs. People were provided with the opportunity to participate in meaningful activities.

The service was up to date with changes to the law regarding the Deprivation of Liberty Safeguards (DoLS). Where needed appropriate referrals were made to external professionals.

There were procedures and processes in place to ensure the safety of the people who used the service. These included risk assessments which identified how the risks to people were minimised.

There were appropriate arrangements in place to ensure people’s medicines were obtained, stored and administered safely.

Staff had good relationships with people who used the service. Staff respected people’s privacy and dignity at all times and interacted with people in a caring, respectful and professional manner.

People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment.

A complaints procedure was in place. People’s concerns and complaints were listened to, addressed in a timely manner and used to improve the service.

Mill Lane Nursing and Residential Home provides accommodation and nursing and personal care for up to 30 older people, some living with dementia.

There were 26 people living in the service when we inspected on 20 July 2015. This was an unannounced inspection.

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.

Where concerns were identified about a person’s food intake, or ability to swallow, appropriate referrals had been made for specialist advice and support. However, this was not always recorded and acted upon. Monitoring of people’s food and fluid intake was not robust enough to demonstrate that people had received what they needed to support their overall wellbeing.

Quality assurances systems were in place and in some areas worked well. However they were not robust enough to pick up the shortfalls we had identified during our inspection and take action to ensure people were provided with good quality care at all times.

Improvements were needed to ensure staffing numbers were assessed against and reflected people’s dependency needs. This was to ensure that people are provided with care that promotes their independence and autonomy as far as possible. Staff training needed to be consistent to support staff to meet the needs of the people who used the service.

People, or their representatives, were involved in making decisions about their care and support. People’s care plans had been tailored to the individual and contained information about how they communicated and their ability to make decisions. Guidance for staff was not always clear about people’s specific care needs and how staff were provided with up to date information about people’s changing needs. Some people were at risk of social isolation especially those people who remained in their bedrooms.

The service was up to date with changes to the law regarding the Deprivation of Liberty Safeguards (DoLS). Where needed appropriate referrals were made to external professionals.

There were procedures in place which safeguarded the people who used the service from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to. Staff understood their roles and responsibilities in providing safe and good quality care to the people who used the service.

There were procedures and processes in place to ensure the safety of the people who used the service. These included checks on the environment and risk assessments which identified how the risks to people were minimised.

There were appropriate arrangements in place to ensure people’s medicines were obtained, stored and administered safely.

Staff had good relationships with people who used the service. Staff respected people’s privacy and dignity at all times and interacted with people in a caring, respectful and professional manner.

People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment.

A complaints procedure was in place. People’s concerns and complaints were listened to, addressed in a timely manner and used to improve the service.

During this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report

Our previous inspection of 29 January 2014 found that the provider needed to make improvements in staff training and supervision, medication management and how they ensured that people were cared for in a safe manner. During this inspection we checked how the provider had addressed these shortfalls. We found that improvements had been made.

We spoke with nine of the 24 people who used the service and three visiting relatives. We spent some time in the service’s lounge to observe the care and support provided and the interaction between staff and people using the service. We spoke with the registered manager, two of the provider's management team and four staff members. We looked at four people's care records. Other records viewed included staff training, quality assurance and health and safety checks. 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 a summary of what we found;

Is the service safe?

When we arrived at the service a staff member looked at our identification and the registered manager asked us to sign in the visitor's book. This meant that appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the registered manager understood when an application should be made, and how to submit one. They confirmed that they had received training in this subject and explained when they had made referrals which further demonstrated their knowledge.

Staff were provided with training in safeguarding vulnerable adults from abuse. This meant that staff were provided with the information that they needed to ensure that people were safeguarded.

The service was safe. Records and discussions with staff showed that there were regular health and safety checks carried out to make sure the service was well-maintained and met people's needs. Equipment in the service had been well maintained and serviced regularly therefore not putting people at unnecessary risk.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

Recruitment practice was safe and thorough. This meant that the appropriate checks had been made on staff to ensure they were able to work with vulnerable people.

Is the service effective?

People told us that they were happy living in the service. One person said, "I get everything I need, I am very happy." Another person said, "I am happy with the care I get, I have no problems."

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

The staff rota showed that the service assessed people's needs to ensure that there were sufficient numbers of staff to meet their needs. Staff were provided with the training and support that they needed to meet people's needs.

Is the service caring?

The staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with kindness and respect. One person said, “There is not one of them (staff) that I don't get on with. They are very loving, you can hear in their voice that they mean it.”

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People who used the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities. We reviewed the minutes from staff meetings which showed that the management had consulted with staff before implementing changes in the service. This helped to ensure that people were provided with a good quality service.

The service had an effective quality assurance system and records reviewed by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Our last inspection of 14 November 2013 found that the provider did not have appropriate arrangements in place to ensure that people who used the service were protected by the procedures for managing medicines. The purpose of this inspection was to check that improvements had been made. We were assured people were being given their medicines as prescribed, however, we noted that the morning medicine round was excessively lengthy and which could have placed people at risk of not having their medicines as scheduled or when clinically appropriate. We noted that whilst there was some good information available about people’s medicines there was also still a lack of written information to assist staff in safely administering some medicines.

Prior to our inspection we were contacted by the local authority who told us that they were investigating a safeguarding concern regarding the pressure area care and prevention in the service. At the time of our inspection they were still investigating this issue.

We checked the care and support provided to the people who used the service. We found that people did not experience care, treatment and support that met their needs and protected their rights.

We checked improvements had been maintained in staff support. We found there were shortfalls in staff supervision and training.

We spoke with seven people who used the service. One person said, “I get what I need.” Another said, “I am happy with the care.”

Our inspection of 3 September 2013 found that staff were not provided with appropriate supervision and appraisal to ensure that they were supported to meet the needs of the people who used the service. The purpose of this inspection was to check that improvements had been made. We found that the majority of staff had been provided with supervision meetings which gave them the opportunity to discuss their work and to receive feedback on their work practice.

During our inspection we spoke with four staff members. Two of these members of staff raised concerns about how medication was managed in the service. We checked the medication processes and procedures and found that there were shortfalls. We saw five people's medication administration records which showed that people had been provided with their medication at the prescribed times. However, these records were checked against the stock of medication and we found that they did not balance.

We spoke with one person who used the service who told us, "Everything is alright here." We spoke with a person's relative who said, "We are very happy with the care, we have no complaints."

Two staff members raised concerns about the support that a person was being provided with by the service and other healthcare professionals. They made a safeguarding referral to the local authority, who were responsible for investigating such concerns. This meant that the staff took appropriate action to ensure that people were safeguarded.

We spoke with eight people who used the service. People told us that they were happy living in the service and that the staff treated them with kindness and respect. One person said, “We have a great time.” Another person said, “I don't care where I live as long as they (staff) look after me and do it how I like." We asked them if they did and they answered, "Yes they are very good." Another person said, "Yes, they (staff) are always kind." We saw that staff interacted with people in a caring, respectful and professional manner.

We spoke with two people's relatives who told us that they were happy with the service that their relatives were provided with.

We looked at the care records of four people who used the service and found that they experienced care, treatment and support that met their needs and protected their rights. People were asked for their consent before they were provided with care and treatment. We found that complaints were listened to and addressed in a timely manner.

Staff personnel records that were seen showed that staff were trained to meet the needs of the people who used the service. However, we found that staff were not provided with appropriate supervision and appraisal to ensure that they were supported to meet the needs of the people who used the service.

We found that people were cared for in a clean and hygienic environment.

The provider had systems in place to monitor and assess the service provided to people.

We spoke with three people whilst they were participating in an activity which involved making seasonal decorations. They told us that they were provided with a range of activities that they found interesting. One person told us that they liked the staff who supported them. There was a lot of chatter and laughing during the activities that we saw. One person laughed and said, "They are a rum lot here." We saw that the staff interacted with people in a caring, respectful and professional manner.

We spoke with three people at lunchtime who told us that they had chosen their meals and this was confirmed in the range of meals that were provided to people. One person said, "The food is always good." Another showed us their meal and said, "It tastes as good as it looks."

Prior to our inspection we had received a concern about the staffing levels in the service and the times that medication was administered during the morning. During our inspection we looked into this. We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. There were enough qualified, skilled and experienced staff to meet people’s needs. We saw that staff were attentive to people's needs and they responded to verbal and non verbal requests for assistance promptly.

Our previous inspection of 13 August 2012 found that the provider was not meeting two standards. This inspection was undertaken to check that improvements had been made. The provider had kept us updated with the improvements that they had made and their plans for further improvements to the service. During this inspection we found that the provider had implemented the improvements that they had told us about.

We spoke with three people who used the service. They told us that they were happy living in the service, the staff treated them with respect and listened to what they said. One person said that the staff were, "Very kind."

People told us that they were always provided with a choice of meals and this was confirmed in our observations during breakfast. One person said, "I always have what I want to eat. If I don't want what is on the menu the cook will do something else. He does a lovely cheese omelette for me."

One person listed the activities that they enjoyed taking part in. They said, "There is always something to do." During our inspection we saw people participating in a karaoke activity.

We spoke with five people who used the service who said that the staff treated them with respect. One person said "They (staff) are kind." Another person said "Yes they are always respectful."

People told us that they were consulted about their care. One person said "I always choose what time I want to go to bed and when I get up." Another person said "I choose where I want to go and can sit where I like."

People told us that they felt that their needs were met. One person said "They can't do enough for you." Another person said that if they were ill the staff would call out a doctor to see them.

People said that they were provided with enough to eat and drink and that the quality of the food provided was good. One person said "You can have seconds if you want and I am never without a drink." We asked another person if they enjoyed their lunch and they pointed to their empty plate and said "I ate it all." Another person said "The food is always good."

People told us they are happy and comfortable living in the home. One person told us, they have lived at Mill Lane about six months, and that they are very happy. This person told us that initially they were upset about leaving their own home, however they have settled in well at Mill Lane and enjoys being with other people. They also told us they have made a friend in the home. A visitor to the home told us that the staff looks after their relative well and they have no concerns.

People told us they and their family had been involved in the implementation of their care plan. People, with whom we spoke, told us they are happy living in the home, very happy with the service they receive and that the staff are very nice and helpful. People told us the home has good activities, they provided examples, including a recent street party for the royal wedding, a visit to Needham Lakes and regular local outings. People told us they have access to the GP and other health professionals, if they need them.

People told us, the have a good choice of food and that they enjoy the food. They also told us that they felt safe living in the home and that they had no cause for complaint, however if they did wish to make a complaint they told us they would speak to the manager.

People told us they were very pleased with the refurbishment of the home and that they found the home a pleasant and comfortable place to live and felt that the staff were helpful and supportive.

Comments taken from the homes quality assurance survey, included:

•“I didn’t want to come into a home, but I feel so much better now I don’t have to worry about anything”

•“The staff are kind and caring… what more could I want”

Relatives’ comments included:

“My relative is treated with dignity and respect, the staff are wonderful”

“I like coming when they have the “Jabberwocky” club, it is so nice to see so much going on”

External stakeholder’s comments about the service included:

•“The nursing staff are very professional”

•“The environment could be improved, but the care is very good”.