This inspection took place on 27 February 2018 and was unannounced.

Following the last inspection on 10 and 11 January 2017 we rated the home ‘Requires Improvement’ overall. We asked the provider to complete an action plan to show us what they would do and by when, to improve the key questions Is the service safe? and Is the service well-led? to at least good. We found improvements had been made to both these key questions. However, in is the service safe?, where people had made a decision to continue to use equipment [bed rails], which did not reach the required safety height, records did not reflect that people had been fully informed of the potential impact on them when continuing to use these. We did find improvements in records relating to medicines and the use of drink thickeners. Although, staff required a better awareness of the potential risks to some people when supporting them to eat safely. In is the service well-led? we found audits were used to identify shortfalls and to drive improvement.

Millbrook Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Millbrook Lodge can accommodate up to 80 people, in one building, which is split into four separate units, each of which have separate adapted facilities. Three of these units care for people with nursing needs and one unit for people without nursing needs, where some also lived with dementia. Each unit provides single bedrooms which have private toilet and washing facilities. On each unit is a lounge, dining room with kitchenette area and additional communal bathrooms and toilets. The home provides a large and secure adapted garden. On the ground floor there was a central lounge with a tea room area and a separate hair dressing salon.

The home had a registered manager who had been in post since 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.

At this inspection we rated the service ‘Good’ overall.

People told us they felt safe. Risks to people were identified and managed appropriately. Where people were able to make decisions, about risks which may have an impact on them, they were supported to do this. We have made a recommendation about the records kept about the information given to people, which supports them to make independent and informed decisions about the use of bed rails. People received their medicines safely and clear records were kept in relation to these. This reduced the risk of potential errors associated with medicines.

Risks relating to people’s nutrition and the potential risk of choking on food or drink had been assessed and action taken to reduce these. Staff were well supported and received training in order to meet people’s needs. We have made a recommendation about reviewing the training given to staff in relation to supporting people who are at high risk of choking.

People had good access to medical support and other health and social care professionals when needed. The principles of the Mental Capacity Act were met. 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.

Care was provided in a kind and compassionate way. Staff took into consideration people’s wishes and preferences and tailored their care around these. People’s dignity and privacy was upheld and their diverse needs and beliefs supported. Relatives and friends were made to feel welcomed and were seen as integral to supporting peopl

We carried out a comprehensive inspection on 10 and 11 January 2017. At our last inspection in June 2014, the care home was meeting the legal requirements.

The inspection was unannounced. Millbrook Lodge provides nursing and personal care for up to 80 people. At the time of our inspection there were 76 people living in the home.

There was a registered manager in place 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 told us they felt safe in the home. They were cared for by staff that had been trained and understood their responsibilities with regard to keeping people safe from avoidable harm and abuse. Risk assessments were completed and risk management plans were in place. However, we found some bed rails and a pressure relieving mattress that were not used in a safe way or as intended.

People‘s healthcare needs were met. People were supported to make decisions. Staff identified when people’s needs changed and they obtained support and guidance from external health care professionals. The home received regular visits several times each week from the local GP practice.

Staff demonstrated a kind and caring approach and they treated people with dignity and respect. Staff knew people well and were able to tell us about people’s likes, dislikes and preferred routines which were reflected in their care records.

There was a range of activities that people could participate in and people were enjoying group activities on the days of our inspection. The registered manager had developed links within the local community and groups such as the local ‘Mother and Baby’ group were held in the home on a regular basis.

People, staff and relatives told us the home was well-managed. People and relatives told us the registered manager was readily accessible and available to them. Staff told us they were well-supported and that the home was a “Good place to work.” Quality assurance systems were in place however their effectiveness at identifying areas of concern or risk needed further improvement.

We found a breach of one of the regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

We found improvements to the standard of care afforded to people who in July 2013 were not having their needs fully met. Staff had received support and training to improve their practice. We also found improvements in the arrangements for identifying risks to people, managing risks and for following up and ensuring these risks had been addressed.

People's care had been delivered in line with their individual care plans. Although most people we revisited or visited for the first time during this inspection were unable to tell us about their care, due to their complex needs, one person had been able to confirm that their care had improved since July 2013. We also evidenced improved outcomes for other people by inspecting their care records, by observation and by talking to staff.

We found some gaps in the recording of care. These examples had either not resulted in the person being harmed or staff were able to describe and confirm the care they had given but had omitted to record. The management of the service had put arrangements in place since July 2013 to improve record keeping and, apart from these gaps, this had been effective.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time of this inspection.

We carried out this visit to follow up compliance actions that were issued in January and April of this year and to assess the care home against further regulations of the Health and Social Care Act 2008.

The compliance actions related to how decisions were made for people who could not provide consent, the subsequent risk assessing and planning of care and record keeping. During our visit on 6 September 2012 evidence was gathered which demonstrated that these compliance actions had been met.

Other regulations inspected against included how people who use the service are respected and involved in decision making, how people are protected against abuse and harm, staff recruitment practices, the management of concerns and complaints and systems for monitoring and quality assurance. All of these areas were found to be compliant.

Although the care home can provide care to up to eighty people across four units, we spoke to two people, two visitors and two care staff in one unit, the manager of the care home and two senior company managers.

The people using the service said "I like it here, there is lots of freedom" and "the staff are very nice and helpful".

The visitors were happy with the care that was being provided to their relative.

This was a very focused, responsive review which included a visit to the service following an incident that we had been made aware of. We were unable to gain the relevant views about the care and services provided because of people's mental frailness. We therefore gathered evidence about these by speaking to staff who provide that care, a relative and by inspecting care records and other relevant documents.

We spoke to people who use the service as well as two visitors.

One person said “I think Millbrook Lodge is a nice place", and another described the home as "lovely".

People also commented on the cleanliness of the home and told us how they liked the en-suite facilities.

We heard positive comments about the staff such as "outstanding" and "great".

People told us that they received enough help to meet their needs and that their privacy was respected.

In this report the name of a registered manager appears who was not in post and not managing the regulated activity at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time. This individual's name will be removed from the register, by us, in due course.

Two Adult Social Care Inspectors and one Expert by Experience carried out this inspection over two days. The inspection was carried out in response to information of concern received by us. We shared this information with other agencies that have a responsibility to protect people from neglect and harm.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

The service was safe because people were protected, their freedom was supported, and their rights were upheld. This was evident in the arrangements in place to protect people who lacked mental capacity. These arrangements adhered to current legislation.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Staff were aware of what could constitute a deprivation of someone's liberty. Some staff had been trained to understand when an application should be made and how to submit one.

The service was safe because processes were in place for staff to learn from accidents and incidents so reoccurrences could be avoided. Risks were managed in the least restrictive way. We observed one person's risks not being managed in line with their care record. Although no harm came to this person, during the inspection, we made managers aware of our observation.

The service was safe because there were sufficient, appropriately trained and skilled staff to meet people's health and care needs. This had been achieved by altering the responsibilities and roles of some staff. Staff who administered medicines had been trained to do this safely.

Is the service effective?

The service was effective because people were seen by appropriate health care professionals to ensure their health care needs were addressed. One person said "carers are really good and supportive" and a relative said "they look after my relative really well here". A visiting health care professional told us the staff had managed the needs of the person they were visiting far more effectively than other services that had been tried.

The service was effective because it ensured people had the correct equipment. This meant people's care was delivered more effectively and safely. Staff were aware of when equipment would not be suitable, such as the use of bed rails, where these may act as a restriction.

The service was effective because it took part in meetings with other health care professionals/services to identify known, potential medical emergencies and effectively plan for situations that may require urgent support from community services.

The service was effective because it ensured that staff received appropriate training and professional development. Where staff were not experienced/skilled there were support systems in place.

Is the service caring?

The service was caring because we observed compassionate and caring interactions between staff and the people who used the service. Observations such as that of a member of staff re-adjusting a person's clothing because they had become exposed told us staff cared and wanted to maintain the person’s dignity.

People told us the service was caring. They said "they (staff) always ask before they do something" and another person said "I am very comfortable, everyone is so friendly". One person said "I have shouted at staff but they never shout back". Another person told us about their "lovely day out" in the mini-bus. This showed that staff cared about people's quality of life and tried to improve this.

The service was caring because we observed staff working sensitively and quietly with people who were less able to communicate and those that were poorly.

Is the service responsive?

The service was responsive because it listened to people's complaints/concerns and took action to improve the service given.

The service was responsive because it acted on alterations to people's needs. Records showed staff had, at times, needed to work closely with other health care professionals to respond quickly to people's altering needs. People’s care plans had been amended as people’s needs changed. People told us staff had responded appropriately to them being poorly or requiring more care. One relative told us they thought staff had responded appropriately to their relative's decline in health. They told us they had an appointment with the GP and staff to review their relative's health and treatment. This meant people's representatives, where appropriate, were consulted about their relative’s care/ treatment.

Some comments from people who used the service indicated they had experienced a substantial wait for staff to respond to their call. One person said "if you want help you just buzz, if it is busy you might have to wait quarter of an hour before someone comes". Comments also indicated that some people perceived staff to be too busy to accommodate their preferences.

Is the service well-led?

The service was well led because the provider had robust management and monitoring systems in place. This meant processes that enabled the service to run smoothly and safely had continued and staff had remained aware of their individual responsibilities.

The service was well led because systems were in place to ensure staff on the units communicated with the management team. There were procedures in place to enable staff to raise concerns, either with the immediate management team or with the provider. We observed one member of the management team visiting the units in order to talk with staff and find out where support was needed as well as to monitor the care being delivered.

The service was well led because the provider ensured the service was robustly monitored. There were systems in place to assess and progress the provider's expectations and measure the service's compliance with the Health and Social Care Act 2008. Where improvements were required the provider ensured these were addressed. Improvements were only signed off as completed once checked by a representative of the provider.

The service was well led because the provider responded to challenges in a proactive manner. Difficulties in the recruitment of nurses had resulted in an increase in agency staff usage. This had caused difficulty in ensuring continuity of people's care. The actions taken by the provider had ensured, for example, that people’s medicines were correctly and safely administered and people received care by staff who knew them. A longer-term strategy to recruit nurses was in place. This meant the provider was not afraid of taking the required action to protect people who used the service and maintain the integrity of the business. This demonstrated proactive and appropriate leadership.