We undertook an unannounced focused inspection of Mill View on 30 October 2018, due to information of concern that we had received regarding an incident at the home. This incident is subject to an investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risks of choking. This inspection examined those risks.

The team inspected the service against three of the five questions we ask about services: is the service safe, effective and well-led? This report only covers our findings in relation to those key questions. No risks, concerns or significant improvement were identified in the remaining key questions through our ongoing monitoring or during our inspection activity so we did not inspect them.

The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Mill View on our website at www.cqc.org.uk At the previous inspection on 28 February 2017 we rated Mill View as Good. At this inspection we identified areas in need of improvement and this meant that the overall rating of the home has changed to Requires Improvement.

Mill View 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 View accommodates up to 70 people in one purpose built two storey building. On the day of this focussed inspection there were 62 people living at the home. People living at the home had a range of needs including nursing needs, mental health needs and some people were living with dementia.

The home had a registered manager who was present during the focussed 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.

Some people were not receiving the support they needed to eat their food. Staff were not deployed effectively to support people in a timely way at lunch time and staff were not always aware of people’s needs. This was identified as a breach of the regulations.

Risks to people had been assessed. However, care plans did not always give staff clear guidance in how to manage some risks and some staff were not all accessing care plans. This meant that people were at risk of not receiving the care they needed. This was an area of practice that needed to improve.

Quality assurance systems were not always effective in identifying shortfalls. Analysis of incidents had led to positive changes in supporting people at meal times. However, these changes were not yet fully embedded and sustained in all areas of the home. This was an area of practice that needed to improve.

People told us they felt safe at the home. People were receiving their medicines safely and staff were knowledgeable about infection control. There were enough staff on duty and recruitment procedures were robust. However the deployment of staff was not always effective, for example at meal times.

People had confidence in the staff skills. One person said, “They are very good here. The staff know how to care for people well.” Staff had received the training and support they needed. One staff member told us, “We have training all the time. The dementia training was very powerful.” Staff described effective team work and there were systems in place to support communication between staff. People’s needs and preferences were assessed in a holistic way. Staff u

This inspection took place on 28 February 2017 and was unannounced. Mill View is a purpose built home providing residential and nursing care for up to 70 people including people who live with dementia, mental health conditions and have general nursing needs. The service provides both long term and respite placements and at the time of the inspection there were 61 people living at the home. Some people were independent but others were living with dementia and had a mixture of dependency levels and needs. Many of the people had difficulties in communicating their needs. This meant that they were vulnerable as they were unable to raise concerns or make basic decisions about their care and welfare needs.

The service had a new manager in post who was about to apply to become the 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 inspection in September 2016 we identified continued breaches of the regulations in two areas. We took enforcement action against the provider. We issued one warning notice in relation to good governance and asked the provider to make further improvements to arrangements for supporting people with food and hydration. We undertook a comprehensive inspection on 28 February 2017 to check whether the required actions had been taken to address the breaches we previously identified. This report covers our findings in relation to these requirements.

Improvements to the governance of the service had been sustained and embedded and this meant that the breach of regulations had been addressed.

Systems for monitoring care provision had become embedded in practice. This meant that risks to people were being effectively managed in a sustained in a consistent way across the service. Clear management and consistent monitoring had led to improvements in the quality of record keeping. This meant that staff had accurate information to support them in providing personalised care to people. People and relatives told us that they had noticed improvements since the last inspection in September 2016. One person said, “I think they have improved quite a bit in the running of this place. All in all, I would say it’s a good place to be.” A relative told us, “It hasn’t been good here but I’d say it is getting better.”

People were being supported to have enough to eat and drink. “Hydration stations” had been introduced around the home to encourage people to help themselves to drinks and snacks. Staff were focussed on ensuring that people were offered regular fluids and snacks. People’s records were being completed accurately and confirmed that they were consistently meeting fluid targets. People told us that they had plenty to eat and drink and our observations confirmed that people were receiving the support they needed. One person told us, “We have lots to drink, if we want, we ask them and they make it straight away.” A relative said, “Staffing levels at meal times are much better and people get the help they need.” The provider had followed their action plan and was now meeting the requirements of the regulations.

People told us they felt safe at Mill View, one person said, “It’s nice here there are lot of people around if you need something, you just need to call out.” A relative told us, “Staffing levels have really improved over the last six months or so, I complained about staffing levels previously but it is much better now.” Our observations confirmed that people were not having to wait for their care needs to be met. Staff were consistently responding to call bells within two minutes and there were enough staff to support people at meal times. Risks to people were identified and care plans detai

The inspection took place on 15 and 20 September 2016 and was unannounced.

Mill View is a purpose built home providing residential and nursing care for up to 70 people including people who live with dementia, mental health conditions and have general nursing needs. The service provides both long term and respite placements and at the time of the inspection there were 67 people living at the home. Some people were independent but others were living with dementia and had a mixture of dependency levels and needs. Many of the people had difficulties in communicating their needs. This meant that they were vulnerable as they were unable to raise concerns or make basic decisions about their care and welfare needs.

The service had a newly 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.

The previous inspection of 23 February 2016 identified a number of continued breaches of the regulations, with regard to inadequate staffing levels, failures in meeting people’s nutrition and hydration needs, poor record keeping, and ineffective quality monitoring systems. We also found a number of areas of practice that needed to improve, including protecting people’s dignity and supporting people to follow their interests. The provider produced an action plan in June 2016 to tell us what they would do to meet the legal requirements.

We undertook a comprehensive inspection on 15 and 20 September 2016 to check whether the required actions had been taken to address the breaches previously identified. Improvements had been made in some areas. However we found continuing breaches in relation to nutrition and hydration and good governance.

We continued to have concerns that records were not always complete and accurate and governance systems and processes were not always robust and effective. There had been improvements in the personalisation of care plans. However this had not been fully embedded and some records were not complete and accurate. It remained that not everyone’s care plan was focussed on their individual needs for example one person’s care plans did not reflect the support that they required to eat even though the care plan had been reviewed. The registered manager had put a number of systems in place to improve monitoring of service delivery such as introducing hydration calendars to ensure people were receiving adequate fluids and introducing mechanisms to check that recording was maintained. However, these systems were not yet all embedded and were not always effective in driving service improvement.

There had been improvements to the meal time experience. However, it remained that not all people were always given the support they needed to eat and drink. The risks of dehydration and malnutrition were not always effectively monitored. We observed one person at risk of malnutrition who was not offered the support they needed to eat their meal. Records showed that they were losing weight. People told us that they didn’t receive a hot drink, or anything to eat following the evening meal until breakfast the next morning. One person said, “Between 5:00pm and 9:30am we get nothing offered to us.” One relative said, “My relative has type two diabetes and I think they should have something in the night between 5:00pm and 9:00am, he has been quite poorly in the mornings. Recording of people’s food and fluid intake was inconsistent and contained gaps and inaccuracies, a member of staff told us “It depends who is on duty.” This meant that the registered manager could not be assured that people were always receiving the food and fluids that they needed.

Although there was a wide range of organised activities available at the home, s

This inspection took place on 23 February 2016 and was unannounced.

Mill View is a purpose built home providing residential and nursing care for up to 70 people, including people who live with dementia, mental health conditions and have general nursing needs. The service provides both long term and respite places and at the time of the inspection there were 62 people living at Mill View.

The service should have a registered manager however currently the person in charge is not registered. 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 previous inspection carried out on 29 November 2014 and 2 December 2014 identified a number of breaches of the regulations with regard to inadequate levels of staffing, poor record keeping, failures in meeting nutrition and hydration needs, lack of staff training and support and ineffective quality monitoring systems. The provider produced an action plan in April 2015 to tell us what they would do to meet the legal requirements.

We undertook a comprehensive inspection in February 2016 to check whether the required actions had been taken to address the breaches previously identified. This report covers our findings in relation to these requirements. Improvements had been made in some areas, however we found continuing breaches of regulation relating to staffing levels, nutrition and hydration, and good governance. Further areas for improvement were identified in relation to maintaining people’s dignity, providing person centred care and ensuring people were supported to follow their interests.

It remained that there was not always sufficient staff to keep people safe and meet their needs. People, relatives and staff told us that there was not time to do more than provide basic care and our observations confirmed this. One person told us “The staff do their best but they are so busy, they are rushed off their feet most of the time.” The provider had an active recruitment programme however their updated action plan confirmed 'We have been unable to significantly reduce the use of agency staff due to the high number of vacancies.' We saw that people were left unattended for what appeared to be long periods of time, people had to wait to have their care needs met and staff were often too busy to spend time talking to people other than when directly providing care.

People were still not always given sufficient support to eat and drink and risks of dehydration and malnutrition were not being appropriately monitored and managed. A visiting relative told us “No one’s been in to see if they’ve had a drink.” We saw that people who had been assessed as being at risk of dehydration were not having fluids offered consistently and records showed that their fluid intake was unacceptably low. People were not always given sufficient support to eat. One person had lost a significant amount of weight and their care plan contained contradictory information regarding the support they needed with eating. This indicated that monitoring and management of risks associated with people’s food and fluid intake was not robust and some people remained at risk of receiving poor nutrition and hydration.

People’s care records were not always personalised and some did not give an accurate reflection of people’s needs. One person said “I’m treated the same as the other people but my condition is different, sometimes the staff don’t understand my behaviour.” Although some care plans were detailed others contained very little information about people’s life history and it was not possible to ‘see the person’ in the documentation in order to promote personalised care. Information specific to the person was sometimes missing or incomp

This inspection was carried out by an adult social care inspector and an expert-by-experience. The focus of the inspection was to check if the provider had taken sufficient action to meet the compliance action set at our visit in July 2013. We considered our inspection findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

This summary is based on our observations during the inspection, discussions with 12 people, six relatives, the manager, the clinical lead, two nurses, one team leader, two carers and the activities coordinator. We also reviewed records relating to the management of the service and four people's care and health records. As some people could not talk with us about their experiences of living at the service we spent time observing how they were cared for and treated by staff. We observed interactions between staff and people who lived at the service for four hours during the morning and lunchtime period.

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

Is the service safe?

People had care plans that were detailed and provided up-to-date information about their care needs. The selection of care plans that we looked at demonstrated that people or their representatives had been consulted and that their personal needs and preferences were reflected.

The service had appropriate systems in place to manage medicines. Medicine was stored, administered, recorded and disposed of in a safe way.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Since our last visit one application had been made. The manager demonstrated knowledge of their responsibilities in respect of this.

Is the service effective?

We found that people’s care plans were detailed and that they had been reviewed on at least a monthly basis. This ensured that the care provided was in line with their individual needs and preferences. One relative told us, “I was party to her care plan at the start and reviews are done every three months and I believe that’s changing to monthly”.

As many of the people living at the service were unable to speak directly of their experience, we spent time observing the care and support that they received. Staff demonstrated skill and experience when supporting people. One person that we spoke with told us, “It’s a nice place to be in if you’ve got to be in a home”. A relative said, “I’ve seen no better care”.

Staff had received training to meet the needs of people living at the service. Staff that we spoke with told us that they felt supported and were able to deliver good care. One said, “We support and work well together, it flows quite easily”.

People's rights with regard to consent were being promoted by the service and staff understood how people's capacity should be considered.

At our last visit we found that the layout and the use of key pads restricted people’s movements and freedom. At this visit we found that the codes were displayed by the doors. This meant that people who were able and safe to move around the service independently were free to do so. One person said, “I can navigate about alright”.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. We spoke with 12 people. They were all satisfied with the care that they received. They told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us, “This is our home and it feels like it” and said, “They can’t do enough for everyone”. Another told us, “I would give this home a glowing reference”. A relative shared, “There’s a lot of compassion here, it’s evident in all the staff”.

Is the service responsive?

People told us that they were able to raise suggestions or concerns and that they were consulted about changes in the service. Relatives told us that they were kept informed and updated if there were any issues or concerns regarding the health of their family member. One relative said, “They always telephone me when X (their relative) is not well”. We found that the service listened and responded to questions and feedback received from people, their representatives and from staff. One relative told us, “The staff are very sensitive to residents’ and relatives’ needs”.

Is the service well-led?

Since our last visit a new manager was in post. Prior to their appointment the post was vacant for five months. The new manager was taking action to monitor and assess the quality of the service. Where necessary, action plans were in place or being drawn up that detailed steps to address any identified shortfalls. This meant that systems were in place that ensured that the quality of service was regularly monitored and assessed. One member of staff said, “It’s (the service) structured and organised”.

Systems were in place to make sure that the manager and staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

This is the services first inspection since it opened in May 2012. We spoke to ten staff, five visitors and 25 people who lived at the service. There were 48 people living at the service at the time of our inspection.

We received consistent positive feedback from people about their experiences and life at Mill View. They told us about the kindness and friendliness of staff and how well cared for they felt. People told us: “I can’t tell you how good it is here, It’s like living at home” and “I only have to ask and I get help” . A relative told us: “We visited so many homes to look around, we were given paper work about Mill View and as soon as we met the staff we knew that this was the place for mum as she would be safe and well cared for here” .

We saw many examples of staff supporting people in a sensitive respectful manner. People told us how staff spoke to them with respect and treated them with dignity. People told us they felt staff knew “What they were doing” and that they had the skills to meet their needs. A person told us “Whenever we have to use the call bell day or night they always come as quick as they can, I don’t recall ever having to wait any length of time”.

We saw how people’s medical needs were supported. A person told us: “The Dr visits once a week but if needed in the meantime they are very quick to let him know I need him”. A relative told us “Since mum has been back here she has improved considerably they are just so good with her and so caring”.

The meal time was relaxed and we observed people being supported to eat their meals in a dignified and timely manner. People described their meal “Nice” “Plenty of it” and “The food is always very good”.

People consistently told us that they felt safe living at Mill View. A relative told us how they had peace of mind as they had much confidence in the staff that their relative was safe from harm and abuse.

A relative told us “It does not matter what time of day I visit it’s always clean and tidy, this then gives me confidence that mum is being looked after”.

People were not able to access freely the facilities within the service as their movement was restricted through the use of key pads on all doors and lifts from each of the units. There was no documentation to suggest that all people who lived at the service were at risk and therefore required their movements to be restricted in this manner.

The inspection took place on 29 November and was unannounced. We returned on 2 December 2014 to complete the visit.

Mill View is a purpose built home that provides residential and nursing care for up to 70 people, including people who live with dementia, mental health conditions and have general nursing needs. The service provides long term and respite placements. At the time of our visit there were 67 people in residence.

The service has 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.

There were not always sufficient numbers of staff to meet people’s needs or to keep them safe. People were at risk of receiving care that was inappropriate or unsafe because their needs were not always regularly reviewed or updated when changes occurred. Where people had particular needs that required monitoring, such as fluid intake, records contained significant gaps.

We found that people who required a pureed diet did not always receive food that was appropriate for their needs. They were also limited by the choice of food available, particularly dessert options.

The registered manager and provider had a system for monitoring the quality of the service provided but identified improvements or changes were not consistently implemented or sustained.

Morale amongst staff was low, they told us because they were too rushed to provide a high standard of care. Suitable arrangements were not in place to monitor the status of staff training and to ensure that staff received refresher training in accordance with the provider’s policy. While staff told us that they had supervision meetings, we found that records were missing and that they had not had appraisals. This meant that staff may not have been supported to care for people safely and to an appropriate standard.

Some people and many relatives were concerned that the standard of care was in decline. They told us that the staff were excellent but they were increasingly busy and did not have time to chat with them. They told us, and we observed, that communal areas were not always supervised. Others shared a most positive experience. One said, “I hear negative things but that’s not my experience. I’m really happy with the home”.

Staff were caring. People, or their relatives, had been involved in planning the care they needed. They were able to make suggestions and felt that they were treated with dignity and respect.

Risks to people’s safety were assessed and generally reviewed. Staff understood local safeguarding procedures. They were able to speak about the action they would take if they were concerned that someone was at risk of abuse. Medicines were managed safely.

People were able to access healthcare professionals, including their GP, dieticians and chiropodists.

The registered manager held meetings with residents, relatives and staff. In the main, people told us that they were listened to and that the registered manager responded to their concerns. There had been positive changes, such as activity provision at the weekend in response to feedback.

The concern over staffing was, however, unresolved in the eyes of some people, relatives and most staff. Staff and relatives did not feel listened to when raising concerns over staffing. This was having an impact on the atmosphere at the home and had created a culture of mistrust. There were also issues with the maintenance of the building, including a lack of hot water, which were taking too long for the provider to put right.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we have told the provider to take at the back of the full version of the report.