The Mill House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Mill House is registered to provide personal and nursing care to a maximum of 45 older people. At the time of inspection there were 33 people using the service.

At the last inspection on 20 June 2016, we rated the service ‘Good’ in all key questions and the service was found to be compliant with all regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we identified that the service was failing to adequately protect people from the potential risk of harm and was in breach of regulations 9, 10, 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A new manager had started working for the service five weeks prior to our inspection and was in the process of registering with the Commission. 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 not meeting the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS.) People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible.

Risks to people were not appropriately planned for and managed. Some staff practice we observed placed people at risk of harm and staff did not demonstrate a good knowledge of reducing risks to people.

There were not enough suitably skilled, supported and knowledgeable staff to meet people’s needs in a timely way, including their social and emotional needs. People told us they were often left alone without staff present and had to wait too long for staff assistance.

People did not receive personalised care that met their individual needs and preferences. There was a task focused culture among the staff team who did not always demonstrate a knowledge of people as individuals and their individual needs. Care plans were not personalised and staff did not have time to read people’s life histories to learn about their past.

People were not adequately supported to be engaged in meaningful activities. The provision of activities for people in the service was poor and people with more specialist needs or who spent time in their bedrooms were not engaged.

Staff did not always treat people with dignity and respect. Observations concluded that staff spoke about people’s needs and shared intimate details of their personal care with other staff in communal areas. On occasions staff spoke about people in a patronising way.

Whilst most interactions between staff and people using the service were caring, some staff members failed to recognise their own poor practice and the poor practice of others and how this impacted upon people using the service. The provider and management team had failed to address these issues promptly enough which meant this culture had been allowed to develop and continue.

The quality assurance system in place had identified shortfalls in the service in September 2018. Despite this, the provider failed to bring about improvement quickly enough. This means that people have continued to receive poor care which could place them at the potential risk of significant harm.

People received appropriate support to maintain healthy nutrition and hydration. However, care planning around the support people required was insufficient to guide staff on how to meet their needs effectively.

People and their relatives were encouraged to feed back on the service in

This inspection took place on 20, 21 and 23 June and was unannounced.

The Mill House provides accommodation, nursing and personal care for up to 45 people, including people living with dementia. At the time of our inspection there were 35 people living in the home.

The registered manager had been in post since 2015. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Risks to people’s safety were managed and minimised. There was consistently enough staff on duty to support people and there were appropriate recruitment checks in place to ensure that the risks of employing unsuitable staff were minimised. Risks to individual’s health and wellbeing were assessed and recorded. Clear guidance was available to staff in order for people to be supported effectively.

Safe practices with regards to the safe storage and administration of medicines were not always observed.

People were supported by staff who had appropriate training for their role and staff were knowledgeable about their role. Staff completed an induction process and were supported through regular supervision.

Staff operated within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguard applications had been made for 18 people living in The Mill House. Best interests decisions were clearly documented with the input from people’s relatives.

People were supported to eat and drink sufficient amounts. Timely referrals were made to relevant healthcare professionals where concerns had been identified. People were seen regularly by a visiting GP.

Staff were caring and encouraged people to be independent and to make choices where possible. Staff knew how to promote people’s dignity and treated people with respect.

Care plans were person centred and people and their relatives were involved in the planning and reviewing of care to ensure that individual needs were met.

People knew how to make a complaint and complaints and concerns were listened to and investigated.

The service was well led. The manager was approachable and there was open and effective communication within the staff team.

There were systems in place to ensure that quality monitoring of the service took place regularly. Audits were completed internally and by senior management which produced clear remedial action plans.

We reviewed the evidence we had obtained during our inspection and used this to answer five key 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 our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

We found the premises to be clean which meant that the risks of infection were being effectively minimised. It was also well maintained. We noted systems in place to ensure the safety of people living, working and visiting the home.

People told us they felt safe with the staff. Many of the staff had worked at the home for several years. One person told us, “They know exactly what they’re doing when they help me."

We spoke with the acting manager about the Deprivation of Liberty Safeguards. They told us they had no concerns about anyone in the home coming under the criteria which would necessitate an application to deprive someone of their liberty. There were aware of what action they would need to take should such a circumstance arise. This demonstrated to us that where there were concerns that the appropriate action would be taken.

Is the service effective?

Most people told us that they were happy with the care and support that they received. A few mentioned that calls bells could be answered more promptly on occasion. We were satisfied that staff knew people well and that this enabled them to provide a good level of care to people. One person’s relative said, “To be honest, [their family member] has a much better standard of life here than when they were at home.”

Is the service caring?

The service was encouraging people to spend more time in communal areas. Easter egg hunts and an Easter bonnet competition had been arranged for the coming Easter weekend. It was clear that a lot of thought and attention to detail had been put in to the design of ‘The Mardle’, a traditionally styled tea room, which had been very attractively decorated and furnished.

We observed that staff were kind and attentive. People were not being rushed when tasks were carried out. One person pointed out one member of staff to us, smiled broadly and told us, “They’re all pretty good, but [person’s name] is my favourite!”

Is the service responsive?

We found that people’s needs were met. Where staff required input from external health professionals referrals and advice were sought promptly. Improvements had been made since our last inspection in December 2013 which meant that assessments were carried out promptly and life and social history information was available for staff to enable them to better understand and support people.

Is the service well led?

We were satisfied that the service was well managed. Staff told us that the new management arrangements had taken a while to adjust to but that the change was for the better. They felt that the service was improving. This view was supported by the substantial reduction in the numbers of complaints the service received. The acting manager was aware that improvements were required in certain areas, for example the catering arrangements, but were confident that the service would continue to improve.

Substantial systems were in place to review the quality of the service delivery on a regular basis.

In this report the name of a registered manager appears who was not in post and not managing the regulated activities at this location at the time of our inspection. Their name appears because the de-registration process had not been completed at the time of this inspection.

We observed the interaction between staff and people using the service and saw that it was warm and friendly. People were treated with respect and in a dignified way. One person told us, "After home this is the next best place to be". Another person said that, "The food is very good and there is always choice".

Care plans were task orientated and did not adequately consider the social and emotional needs of people in an individualised way. The completion of important documents such as agreements to care planning and capacity for people to make decisions for themselves had not always been completed.

The service was clean and tidy, with effective infection control procedures in place although staff were not always following them.

There was a thorough recruitment process in place although previous employment histories needed to be fully explored to ensure only appropriate people were employed by the service.

The service had a quality monitoring and audit process in place, with provider visits occurring each month.