This inspection was unannounced and took place on the 18 June 2018. Mill 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. Mill Lodge is registered to provide accommodation for up to 20 older people, some of whom were living with dementia. At the time of inspection there were 16 people living at the home.

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.’

At our last inspection on 24 and 25 October 2016 we rated the service as ‘requires improvement’. We found the provider was in breach of the regulation regarding good governance. We asked the provider to take action to ensure there were robust quality assurance systems in place to drive improvement within the home. At this inspection, we found the provider had made improvements to meet this regulation.

We found a staffing tool had been developed to ensure there was a sufficient number of staff to support people. People’s individual risks were assessed and staff knew how to support people to reduce their risks. People told us they felt safe and staff knew how to report concerns both within the organisation and externally. The provider had processes in place to ensure safe recruitment of staff. We found improvements had been made to medicine management systems and people told us they received their medicines as prescribed.

Staff received training and had the skills and knowledge to meet people’s needs effectively. Staff sought consent before providing support to people and people were supported to make their own decisions.

People told us they enjoyed their meals and meal times were a pleasant experience. We saw staff encouraged people to drink and eat sufficient amounts throughout the day. People had access to healthcare professionals when required.

People had the opportunity to take part in both group and individual activities. People had been asked what they enjoyed doing and this had been accommodated for. People’s needs were reviewed on a regular basis and people and their relatives were involved and felt listened to. People and relatives knew how to complain and felt confident in doing so.

People were supported by staff that knew them well. Staff were kind and caring towards people and promoted their independence.

The provider had made improvements to their quality assurance audits, ensuring they identified trends from incidents. The provider had action plans in place to drive improvement. People and relatives spoke positively about the registered manager.

This unannounced inspection took place on 24 and 25 October 2016. At our last inspection in September 2015 we rated the service as ‘requires improvement’ in all areas we inspected. We found the provider was in breach of the regulation regarding need for consent. We asked the provider to take action to ensure there were arrangements in place to gain people’s consent. When we carried out this inspection the regulation had been met although some improvements were still required in some areas. Mill Lodge is a care home which provides accommodation and personal care for up to 20 older people. At the time of our inspection 19 people lived at the home.

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.

People’s individual risks were not always assessed and guidance was not available for staff to refer to. People were supported by an adequate number of staff. Improvements were needed to the management of medicines to ensure people received their medicines safely and as prescribed. People told us they felt safe living at the home. Staff knew what action to take if they had any concerns about people’s safety. Staff received training and felt they had the skills to meet people’s needs. The provider had safe processes in place to recruit new staff and carried out pre-employment checks.

There was a system in place to assess people’s capacity to make certain decisions. Staff were not aware of the people who were being deprived of their liberty. Staff obtained consent from people before they provided care. People told us they enjoyed their meals and had sufficient to eat and drink. People told us they had access to healthcare professionals when needed.

People and their relatives felt staff were kind and friendly. Care records were not always reflective of people’s needs. People had opportunity to take part in activities although these did not always reflect people’s individual interests. People were confident if they had any concerns or complaints they would be listened to and the matter appropriately dealt with.

Staff understood their roles and responsibilities and felt supported by the registered manager. Quality assurance systems did not identify issues found during the inspection.

We found one breach of the HSCA 2008 (Regulated Activities) Regulation 2014 Regulation 17- Good Governance. You can see what actions we told the provider to take at the back of the full version of this report.

This inspection took place on 18 June 2015 and was announced. At our last inspection on 1 August 2014 the provider was meeting all of the regulations reguired by law.

Mill Lodge Care Home operates as a residential home and as a domiciliary care agency. This inspection was of the domiciliary care agency known as First for Care at Home. As the service is registered with us under the name of Mill Lodge Care Home this is the name we shall use throughout this report. We have published a separate report for the residential home that was inspected on 16 and 17 June 2015.

Mill Lodge Care Home provides personal care for people in their own homes. At the time of our inspection there were 16 people using the service.

There was no 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.

People were not always protected from harm due to inadequate management of risk by the provider. Accidents and incidents were not recorded formally or reviewed by a manager. People’s health and well-being was not protected through the effective use of care planning and the assessment of risk. We found that areas such as ensuring people’s skin remained healthy and intact and safe moving and handling of people were not managed effectively.

People were being exposed to risk of harm as their medicines were not managed safely. Staff were administering medicines without their training or competency in this area having been checked by the provider. Staff were not keeping records of the medicines people needed and their administration to ensure that people received their medicines as prescribed and were kept safe.

The provider was not using safe recruitment practices. We were unable to find evidence that all of the required pre-employment checks to ensure that only suitable people were employed had been completed as required. Background checks such as ID checks and referencing were insufficient.

Relatives told us that there were insufficient numbers of care staff to effectively meet people’s needs. Staff told us that they needed more staff within the care team in order to provide the support people needed.

We found that people’s human rights were not being upheld as they were not being supported to consent to their care, if they were able to, in line with current legislation and guidance. Decisions that were made on people’s behalf were not recorded and there was no evidence that decisions were made in people’s ‘best interests’.

People were not supported by a staff team who were trained and whose competency in their role had been fully checked. Training records showed that staff had not received all of the training the provider deemed as essential to keep people safe from harm. Staff had not received regular one-to-one meetings with a manager to ensure that they were competent and fully supported in their roles.

We found no evidence that people were involved in decisions about their care or that their choices were taken into account in their plans of care. Insufficient records were kept within the service to allow us to review how people’s preferences were reflected in the care they received. The care records that we reviewed did not reflect the care that was given to people. The provider had not reviewed the care people received to ensure it met their needs and preferences.

Relatives told us that the staff team were caring in their approach. We were told that staff took time to talk to people and developed effective relationships with them. There was insufficient documentation kept to provide evidence to show that people’s dignity and independence was supported.

There was no system developed by the provider to record or monitor complaints to the service. Relatives told us that they felt frustrated when they tried to raise a complaint. They told us that they did not feel listened to nor did they feel their complaint had been addressed.

The provider had failed to ensure that there was a robust management structure in place. Staff and relatives were unsure as to who the current manager of the service was. During the inspection the staff running the service were unable to produce evidence to show that the service was meeting all areas of the regulations. People were not supported by staff who were motivated and working within an open and transparent culture where they were supported to question and improve their practice.

People were not supported by a service with robust quality assurance procedures in place. No systems were in place to identify, analyse and monitor issues and areas of improvement within the service. Management meetings and reviews had not taken place. There was no action plan to show that the provider had identified issues and areas of improvement with any aspect of the service.

We found 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 this report.

The overall rating for this provider is ‘inadequate’. This means that is has been placed into ‘special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made
• Provide a clear timeframe within which the providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration

Services placed in special measure will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Following our inspection, we were informed by the provider that they have decided to remove rhe regulated activity of personal care. This means they intended not to continue a domiciliary care service from 5 July 2015. We have received an application from the provider to cancel their registration and this was being processed at the time this report was published. The provider has informed us that they have submitted this cancellation in order to focus on driving improvements within their residential home in order to ensure they are meeting the regulations.

We carried out this inspection in response to concerns that we received about people's care and welfare and staff training. We looked to see what improvements had been made in this area.

On the day of the inspection there were 20 people living at the home but they were not all able to verbally express their views so we observed how they were supported. We spoke with three people, three members of staff who supported people, two relatives and the registered manager. We looked at two people's care records.

Below is a summary of what we found. The summary is based on our observations during the inspection.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that people were being supported safely by staff. Where equipment was needed to support people and reduce any potential risks, we found that it was available. One person we spoke with told us that staff used equipment to support them getting in and out of bed.

Staff we spoke with told us that equipment was available to support people, and our observations on the day confirmed this. This meant that equipment was available to support people in a safe way.

A relative we spoke with said, "I do feel X is safe in the home".

Is the service effective?

We found that appropriate documentation was being used. Risk assessments were being used to identify potential risks and the assessments highlighted to staff how people should be supported. Staff we spoke with told us that training was available in using moving and handling equipment, and people who needed to be moved by staff, were only moved using a hoist or a lifting belt.

Is the service caring?

Our observations were that staff were very caring and supportive to people. People we spoke with confirmed this. One person said, "I have no complaints the home and staff are really good". We saw staff asking people if they were okay and we saw people being able to eat their meals when they wanted to. One person we saw was still completing their meal after lunch time had finished, and staff constantly checked to make sure they were okay. This meant that people were supported in a caring manner.

Is the service responsive?

We informed the registered manager why we were inspecting the service and found that the registered manager responded to us appropriately offering any support they could provide. One relative we spoke with told us that if they had a concern they would speak with the manager. They went onto say that, "The manager and staff were very friendly and professional".

Is the service well-led?

We found on arrival to the home that the registered manager was supposed to be on leave, but was at the home supporting in the kitchen with agreement from the provider who was on holiday. The person who was managing the home was a senior carer who had been asked to cover the home during the absence of the registered manager by the provider. During our initial discussions with the registered manager it became apparent that the senior who had been put in charge by the provider was not qualified to do so. This had been raised with us prior to our inspection.

As a result the registered manager accepted that while they were on the premises they were in charge, and resumed the role of registered manager. The manager supported us on the day of the inspection and assisted us with all the information we needed.

We found that audits/checks were being carried out by the registered manager to ensure the quality of the service to people. However there was no evidence that the provider was auditing the quality of the service provided by the manager.

During our visit we spoke with people who lived at the home, visiting relatives, staff and the manager. We saw positive interactions between staff and people living at the home.

We looked at people’s care plans. Appropriate information and risk assessments were in place. People's care was reviewed appropriately and professional health advice was sought when necessary.

We saw that people who used the service were provided with a choice of suitable and nutritious food and drink. The people we spoke with said the food was good and choices of meals were available.

The staff told us the equipment required to deliver care to people in a safe manner was available, for example hoists for moving people unable to stand. Measures were in place to ensure the premises was adequately maintained. However maintenance to the forecourt of the home was required.

We saw evidence that training was available. The staff we spoke with confirmed they had regular one to one meetings with the manager and felt supported in their role.

There was a policy and procedure in place to ensure complaints made to the home were investigated and responded to appropriately.

People living at the home and visitors to the service were complimentary about the staff saying, “Staff are really good to me, they are really nice”

During the inspection we saw positive interactions between staff and people living at the home. One staff member said, “Everyone gets on really well together it’s a really friendly atmosphere”.

We looked at people’s care plans, and appropriate information and risk assessments were in place. People's care was reviewed appropriately and professional health advice was sought when necessary.

The home had a system for recording and managing incidents and concerns. The staff we spoke with knew the procedure to follow if concerns were identified. One staff member said, “If I have any concerns I can go to the senior staff”.

We saw evidence that training was available. The staff we spoke with confirmed they had regular one to one meetings with the manager and felt supported in their role.

Systems were in place to monitor the quality of the service people received.

Walsall Council told us about a recent incident in the home. One of the people living in the home had an accident and had been injured. We visited unannounced in response to the incident and focused mainly on safety issues in the home.

We had limited time to speak and observe care practice in the home. We spoke to the manager and provider and looked at some of the home’s records.

We saw staff speak kindly and patiently to people living in the home.

The atmosphere was relaxed and some people were outside in the garden enjoying the warm weather.

We found that staffing levels had been increased in response to the recent incident. The manager and provider will need to ensure that future staffing levels are based on a needs analysis and risk assessment of people's individual and collective needs.

We found that the manager was not fully aware of what action she and her team should take if they became aware of a safeguarding incident in the home. So people may not be fully protected from the risk of abuse.

We had some concern about how health and safety was being managed. When we spoke to the manager and provider they responded positively to the issues raised to reduce the risk of a reoccurrence of this incident. They told us that they would take action to ensure people’s safety.

The inspection took place on 23, 24 and 25 September 2015 and was unannounced. At the last inspection in June 2015 we required the provider to improve how care was provided and to improve how staff were checked prior to their employment. The overall management of the service also needed to be improved. We found that some actions had been completed and further improvement was required in some areas.

Mill Lodge Care Home is a residential home providing accommodation for 20 older people who require personal care. At the time of the inspection there was no registered manager in place. 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.

People’s needs weren’t always met at the time they needed support due to staff not being on hand to help them. The provider had improved their recruitment processes to ensure staff employed were suitable.

People told us that they received their medicines as prescribed. We observed safe systems in place around the management and administration of medicines. People told us that they felt safe living at the service. Staff could identify potential signs of abuse and knew how to report concerns if they were to arise.

People were not always protected due to effective risk assessments not always being in place to identify and manage any risks to their health and well being. Accidents and incidents were recorded and monitored in order to minimise any future risks to people.

People’s human rights were not always maintained in line with the requirements of the Mental Capacity Act 2005 (MCA). Staff were not identifying where people might lack capacity to make decisions for themselves and making ‘best interests’ decisions in line with this legislation.

Some people told us that staff had the required skills and knowledge to support them effectively. Others told us that they felt staff needed to develop skills further in certain areas. Staff told us that support and training was much improved in recent months.

People told us they enjoyed the food and drink they received at the service. People were given a choice of meals and drinks. People were supported to access healthcare professionals where needed.

People’s dignity was mostly upheld, however, we were told that some people were not always wearing their own clothes.

People told us that staff were very caring. We observed kind, patient and compassionate interactions between staff and people living at the service. People were involved in some day to day choices about their care. Visitors were encouraged and people were supported to maintain important relationships.

People told us that they had not been involved in the development of their care plan. The provider had begun to obtain personalised information about people’s life history and preferences to help develop individual care plans.

People living at the home, visitors and staff told us that activities were improved within the service although there was still not sufficient stimulation for people living at the service.

People told us that they felt able to provide feedback to the provider and make a complaint if necessary. They felt that their concerns would be listened to and acted upon.

The provider did not yet have effective systems for ensuring that risks to people were identified and mitigated. People were not always supported by staff whose competency had been checked by the provider. Quality assurance systems were being developed and the provider had begun to complete checks within the service.

People were supported by a committed team of care staff who were passionate about their work. They spoke highly of the management of the service. Staff spoke of the high levels of improvements made within the service by management. People living at the home, visitors and staff told us that they felt the culture was open and management were approachable.

We found that the provider was in breach of some regulations under 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.