This focused inspection took place on 3 December 2018 and was unannounced. Mill River 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.

Mill River Lodge is situated in Horsham in West Sussex and is one of a group of homes owned by a national provider, Shaw Healthcare Limited. Mill River Lodge is registered to accommodate 60 people. At the time of the inspection there were 57 people accommodated in one adapted building, over three floors which were divided into smaller units comprising of ten single bedrooms with en-suite shower rooms, a communal dining room and lounge. These units provided accommodation for older people, those living with dementia and people who required support with their nursing needs. The home also contained an unregulated day service facility where people could attend if they wished; however, this did not form part of our inspection.

Since the previous inspection on 15 May 2018, the registered manager had left. A registered manager is a ‘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 home is run. The management team consisted of an acting manager, an acting deputy manager and team leaders. A registered manager from one of the provider’s other homes managed the home three times per week. This provided clinical oversight for the registered nurses and people who received nursing care. An operations manager also regularly visited and supported the management team.

We carried out an unannounced comprehensive inspection on 15 May 2018. The home was rated as ‘Requires Improvement’ for a third consecutive time and a breach of legal requirements was found. This was because there was a lack of person-centred care. Not all people had access to activities or sources of stimulation to occupy their time. Quality assurance audits were not always conducted. Records to provide guidance to staff, as well as document their actions, were not well-maintained and were sometimes illegible. The registered manager and provider lacked oversight of the shortfalls that had been found as part of the inspection. Notifications, to inform CQC of specific incidents or events had not been submitted. There was a risk that because of this we would were not aware of incidents and did not have sufficient oversight to ensure the appropriate actions had been taken. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of Regulations 9 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mill River Lodge on our website at www.cqc.org.uk. Following this inspection the overall rating remains 'Requires Improvement'.

At this inspection we found that some improvements had been made. The provider had arranged for a registered manager, who was also a registered nurse, from one of their other homes, to manage the nursing floor three days per week. This ensured that there was clinical oversight of people’s nursing needs and of the nursing decisions taken by staff. Quality assurance processes were conducted. When areas for improvement had been identified these were monitored and actioned. The management team acknowledged that progress had been made and told us that further improvements were planned.

There were concerns

The inspection took place on 15 May 2018 and was unannounced. Mill River 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.

Mill River Lodge is situated in Horsham, West Sussex. It is one of a group of homes owned by a national provider, Shaw Healthcare Limited. Mill River Lodge accommodates 70 people across seven units, each of which have separate bedrooms with en-suite facilities, a communal dining room and lounge. There are also gardens for people to access and a hairdressing room. The home provided accommodation for older people, those living with dementia and people who required support with their nursing needs. At the time of our inspection there were 62 people living at the home.

The home had a registered manager. A registered manager is a ‘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 home is run.

At the previous inspection on 26 August 2016 the home received a rating of ‘Requires Improvement’ and was found to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, we asked the provider to complete an action plan to show us what they would do and by when to improve the key questions of safe and well-led to at least good. This was because there were concerns regarding the oversight of the service. Quality assurance audits, to identify areas for improvement, had not been completed. Actions resulting from the provider’s audits had not always been addressed. The provider lacked oversight of the systems and processes within the home. Other areas identified as needing improvement related to the deployment of staff to meet people’s needs in a timely manner. At this inspection the sufficiency and deployment of staff had improved. However, we continued to have concerns with regards to the managerial oversight and the provider was found to be in continued breach of the regulations. This is the third consecutive time the service has been rated as 'Requires Improvement'.

Systems and processes were not sufficiently monitored, nor action taken, to ensure that the service was to the standard people had a right to expect. The registered manager had not completed all of the provider’s audits to monitor the service. It was not always evident if actions required by the provider had been completed. The provider had conducted their own audits and these demonstrated that the failure to conduct audits and comply with required actions was a consistent and on-going issue. Records to document people’s care and treatment, as well as those to monitor the service, were not always completed in their entirety. The registered manager and provider had not ensured that the service people received continued to improve. These areas of practice were of concern.

People and their relatives told us that staff were kind and caring. One person told us, “The staff are very kind”. Most people were treated with respect and dignity. However, not all people were treated in this way and person-centred practice was not always evident. People’s needs, preferences and abilities had been documented in care plans. These informed and guided staff’s practice to enable them to meet people’s needs in a way that people preferred. Despite this specific and person-centred information, staff did not always ensure that people’s expressed needs and beliefs were respected. This related to a person’s beliefs as well as their preference for female care staff. This was an area of concern.

The provider and registered manager had not always notified us of events and incidents that had occurred at the home. This did not always enable us to have oversight to ensure people were safe.

Risk ass

This service is registered to accommodate 70 people who require nursing care or support with their personal care. The service specialises in supporting older people, people with dementia and other health conditions such as Parkinson’s, diabetes and pressure area care. There were 57 people living at the service at the time of the inspection three of whom were in hospital.

This comprehensive inspection took place on the 24 August 2016 and was unannounced.

The accommodation was arranged over three floors. The upper floors were accessed by a shaft lift or flight of stairs. There was level throughout and access to a secure garden. There is limited allocated parking at the location and car park passes are available to visitors.

The service had a registered manager. 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 the last focussed inspection in September 2015 the provider was heavily reliant on agency staff and that on two nights in the months leading up to the inspection the service had operated without a registered nurse. This was an area of practice we identified as needing to improve. At this inspection we found the service had always operated with a nurse on duty and the provider had recruited more care staff. People told us they felt safe in the service however the deployment of staff in one area of the service was an area of practice we identified as needing improvement.

There was a comprehensive quality assurance system in place to monitor quality and identify areas for improvement however this was not being effectively implemented. Therefore opportunities to identify and rectify shortfalls in the quality of the service and drive improvement had been missed. At the last comprehensive inspection in February 2015 we assessed the provider needed to make improvements in relation to recording people’s involvement in meaningful activities and reviewing of their care however these improvements had not been made.

People were supported to eat and drink sufficient amounts and enjoyed the food. Special diets were catered for and drinks and snacks were freely available throughout the day. People were provided with appropriate levels of support at meal times.

People’s privacy was protected and people were treated with dignity and respect by kind and caring staff. A relative told us “The staff are very helpful and very friendly, so far mum is very happy”. Another relative told us “Staff know her, they understand her”. Visitors were welcomed and had the opportunity to attend ‘family meetings’ at which they could give their views on the running of the service and make suggestions for improvements. People were able to personalise their rooms and bring their own furniture and thought had gone into making the environment dementia friendly and assist people with orientation around the service and to their rooms. .

People’s health care needs were met and professional advice and support was sought from health care professionals such as GP’s and district nurses as and when needed. People were supported by competent staff who received the training and support they needed to undertake their role and effectively meet people’s needs. One person told me “They know their jobs”.

People received their medicines on time and they were administered by staff who were trained to do so. Measures were in place to reduce the risk of harm occurring and protect people from abuse. Accident and incidents were recorded, collated and analysed to identify and themes and trends so the provider could take steps to reduce the risk of reoccurrence. Staff understood the need to gain consent and worked in accordance with the Mental Capacity Act (MCA).

There were processes in pl

We carried out an unannounced comprehensive inspection of this service on 3 and 17 February 2015. At which a breach of legal requirements was found. This was because legal consent had not been obtained for the use of restraint for one person whilst delivering personal care and staff did not have access to relevant guidance on how and under what specific circumstances they could use this restraint.

After the comprehensive inspection, the provider wrote to us and sent us an action plan detailing what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on the 6 September 2015 to check that they had followed their plan and to confirm that they now met legal requirements. At our focused inspection on the 6 September 2015, we found that the provider had followed their plan in relation to obtaining consent for the use of restraint which they had told us would be completed by September 2015 and legal requirements had been met.

We had also received concerns that the use of agency staff was high and the staffing levels at the service were not sufficient to meet people’s needs. As part of our focused inspection we checked the arrangements for ensuring that sufficient numbers of appropriately skilled and qualified staff were deployed.

This report only covers our findings in relation to these two topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Mill River Lodge’ on our website at www.cqc.org.uk’

Mill River Lodge provides accommodation for 70 older people. It offers nursing and personal care for older people with physical frailty and for older people living with various stages of dementia. There is level access throughout the building and grounds and a passenger lift to provide access to people who have mobility problems. On the day of our inspection 66 people lived at the service.

The service did not have a registered manager. 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 and associated Regulations about how the service is run. The person in day to day charge of the service is referred to as the acting manager throughout the report.

Staff were now aware of under what specific circumstances they could use this restraint and guidance was available to them as to how this should be undertaken. A mental capacity assessment had been completed for the person concerned and an application for a Deprivation of Liberty Safeguards had been made to the local authority. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes.

Staffing levels were determined by assessing people’s dependency needs and staff vacancies and expected leave was planned for. The agreed staffing levels had been maintained the majority of the time. On occasions when agreed staffing levels had not been achieved it was evident that this was due to last minute unforeseen circumstances. One member of staff told us staffing was sometimes an issue due to last minute sickness, they told us, “They seem to do their best to try and get someone else”. On these occasions the provider had taken steps to try to cover these shifts but had not always been able to do so. People’s needs had been met and no harm had occurred as a result of them operating short staffed. However, we have assessed this as an area of practice that requires on-going improvement.

Cover for staff vacancies and staff expected leave was planned for. The use of agency staff to cover these shifts was high but the same agency staff were used on a regular basis and the use of agency staff had not impacted on the quality of care delivered to people. All agency staff underwent an induction to the service before they worked unsupervised and were aware of people’s needs.

People received appropriate support in a timely manner feedback from people and their visitors was positive. One person told us, “Oh they are generally very good I don’t remember ever having to wait for help.” Another person told us, “Oh it’s lovely here I just have to shout and they come and help”. A visitor commented, “Staff are always rushed off their feed feet they don’t seem to stop, they have some very challenging people to look after, but they do it with such kindness and compassion” and “There seems to be more of the same faces, regular staff Mum seems to know all the staff and they know her so it is such a comfort for us knowing this”.

Recruitment continued to be a challenge for the service. The provider was continuing to advertise locally and nationally in order to fill their vacancies.

There were 65 people living at Mill River Lodge at the time of our visit.

We spoke with one person. They told us that “The staff order their medicines for them and each month they received them. They keep their medicines in a locked draw in their room to which they have a key. Each day they transfer the medicines they need to a pill reminder”.

We spoke with four members of staff and the manager. One member of staff told us, “When the people require blood tests to check the effectiveness of their medicines the dates are put in the diary and on the board in the clinical office". The manager said, “Before we can look after people with more complex needs the staff will require additional training and competency assessments". We also observed the administration of medicines at lunch time on the first floor.

Concern had been raised with CQC relating to the management of medicines within the service. Therefore, this visit was carried out by a specialist pharmacy inspector who looked at the use and management of medicines within the home.

You can see our judgements on the front page of this report

People were protected against the risks associated with medicines because the provider does have appropriate arrangements in place to manage medicines.

During our visit we met and spoke with 20 of the 65 people using the service. People told us they were satisfied with the service they received. Their comments included,

“They look after us well and the food is quite good.”

“I like it here because I have company. I never feel lonely.”

We also spoke with the manager, an administrator, the unit manager for the dementia care unit, two nurses, and four care staff.

Some people using the service had dementia care needs, which meant they might have had difficulty describing their experiences of the service. We gathered evidence by spending time watching how people spent their time, the support they got from staff and whether or not they had positive experiences.

We saw that staff addressed people by their preferred names. Personal care was carried out in private. Staff were discreet when explaining to people the tasks they were undertaking to support their care needs.

We toured the home, observed care and spoke with people living in the home. We spoke with six people individually and with three groups of people at dining tables. People told us they were generally happy with the care in the home. One person told us that the staff "Look after me very well", another told us that there was not continuity with staff, another said "Sometimes you have a carer on duty that you know and then they get moved to another unit"

We spoke with the acting manager and four staff. The home has been going through a period of change as it had lost two managers since out last inspection. The staff felt supported through this change. One staff member told us the management "involves staff in the changes"

We spoke with two relatives on the telephone. Both were happy with the care offered in the home and feel they are communicated with well. One did tell us that they felt the garden had not been well maintained this year. The other told us that there had been many improvements in the home of late and that it "was much more like a home now". We spoke with the district nursing team who told us that communication was much improved in the home. They have met with the acting manager and have proposed ways to make their regular visits twice a week more efficient. People we were told were referred appropriately and promptly to the team.

We spoke with seven people living in the home who told us they were happy with the care they received in the home. They confirmed that there was choice in daily activities and daily routines. There was a violinist in the home at the time of the visit which the people seemed to enjoy. One person told us "The activities are good; the violin player today was good. They try to take us out to the shops but as there is only one activities co-coordinator at the moment, it is a bit difficult"

People we spoke with told us their needs were assessed prior to admission to the home. We were told care needs were discussed with themselves and their families. They told us they were aware of their care plans.

We were told there was good choice of food and that they were asked daily what they wanted to eat the next day. We were also told that if they changed their mind they were always offered something else. One person told us “ The meals are quite impressive”

We were told that call bells were answered quickly and that staff were respectful.

One person told us "Compared with other homes, this one is up there at the top"

We spoke with two relatives, one was entirely satisfied with the care in the home and the other told us it was mixed depending on who was on duty but that in the main care needs were met.

People said they were well looked after, and that staff were very kind. One person said that “staff are good but we need more staff”. They felt they could approach staff if they had a problem.

People’s comments about the food were varied – for example “it’s okay and I like it”, “food is very good and I am helped to choose”, and “okay if you like that sort of thing”. Two people said the food was sometimes not well cooked.

People told us that the home was kept clean, and one person said “any accidents are cleaned up straight away”.

People we talked to were happy with the facilities in their bedrooms, and liked the garden and the living areas.

Mill River Lodge provides accommodation for 70 older people. It offers nursing and personal care for older people with physical frailty and for older people who are suffering from dementia. There is a passenger lift to provide access to people who have mobility problems. There were a total of 96 members of staff employed plus the manager. On the day of our visit 66 people lived at the home.

At our inspection to Mill River Lodge in June 2013 we found the provider did not always support people to make informed choices with regard to their care. At this inspection which was carried out on 3 and 17 February 2015 we found improvements had been made. However we identified areas where improvements were still needed.

The service did not have a registered manager. 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 legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. Mill River Lodge has been without a registered manager since June 2013. A new manager has been appointed and was in the process of applying for registration.

People told us they felt safe. Relatives told us they had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of harm.

Care records contained risk assessments to protect people from risks and help to keep them safe. These gave information for staff on the identified risk and guidance on reduction measures. There were also risk assessments for the building and contingency plans were in place to help keep people safe in the event of an unforeseen emergency such as fire or flood.

Thorough recruitment checks were carried out to check staff were suitable to work with people.

Relatives and staff told us that staffing levels could be improved. The provider was in the process of conducting a review of staffing levels based on the number of people living at the home. This review also took into consideration people’s support needs.

People were supported to take their medicines as prescribed by their GP. Records showed that medicines were obtained, stored, administered and disposed of safely

Each person had a plan of care. However these did not always provide staff with the information they needed to support people effectively. Reviews of care plans did not show who was involved in the review process and any progress or lack of it was not recorded. The provider identified that more information was required in some care plans and was currently undertaking a review of all care plans. Although this was being carried out it had not yet been fully completed for all care plans. Staff knew what support people needed and how this should be provided.

Staff were supported to develop their skills by regular training. The provider supported staff to obtain recognised qualifications such as National Vocational Qualifications NVQ or Care Diplomas (These are work based awards that are achieved through assessment and training. To achieve these awards candidates must prove that they have the ability to carry out their job to the required standard.) People said they were provided with the training they needed to support people effectively.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that although the provider had suitable arrangements in place to establish, and act in accordance with the Mental Capacity Act 2005 (MCA) this was not always applied in full. This was because some people who lacked capacity had not yet been fully assessed regarding their capacity to agree to their care and treatment. The provider and manager understood their responsibility with regard to Deprivation of Liberty Safeguard (DoLS) and they had applied for authorisation under DoLS to ensure people were protected against the risk of being unlawfully deprived of their liberty.

We observed activities taking place for people. However improvements could be made in how recording of activities took place. This would help ensure that people were not at risk of social isolation. We observed staff trying to engage with people but as staff were always busy there was little time for social interaction.

People were satisfied with the food and said there was always enough to eat. People were given a choice at meal times. People were able to have drinks and snacks throughout the day and night. Meals were balanced and nutritious and people were encouraged to make healthy choices.

Staff supported people to ensure their healthcare needs were met. People were registered with a GP of their choice and the manager and staff arranged regular health checks with GPs, specialist healthcare professionals, dentists and opticians. Appropriate records were kept of any appointments with healthcare professionals.

People told us the staff were kind and caring. Relatives had no concerns and said they were happy with the care and support their relatives received. Staff respected people’s privacy and dignity and used their preferred form of address when they spoke to them. Observations showed that staff had a kind and caring attitude.

People told us the manager and staff were approachable. Relatives said they could speak with the manager or staff at any time. The manager operated an open door policy and welcomed feedback on any aspect of the service. Regular meetings were booked to take place with staff, people and relatives.

The provider had a policy and procedure for quality assurance. Weekly and monthly checks were carried out to help to monitor the quality of the service provided. The provider had carried out an audit of the service and identified areas for improvement. An action plan had been put in place to monitor and check that these improvements were taking place. However these improvements were not yet completed or embedded in practice to ensure they could be sustained. We did not find evidence that there were effective systems so management and staff could learn from any accidents, complaints or incidents. We have made a recommendation regarding this matter.

We made a recommendation regarding the information containined in plans of care and the care plan review process.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to 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