CQC report explained · a nursing home
What the CQC found at Florence Mill Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that medicines were not always managed safely. Other safety arrangements had improved, including risk assessments, staffing, safeguarding and incident reviews.
- Effective?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- The provider's checks identified some issues but did not always make sure they were fixed across the home. Care planning records were not always current or detailed enough.
What inspectors found, March 2024
Rated Requires Improvement; inspectors found safer care than before, but medicines and the home's improvement systems were still not reliable enough.
This was an unannounced focused inspection on 4 and 15 May 2023. Inspectors spoke with 27 people, 6 family members and 15 staff. They observed care and checked care, medicine, recruitment and management records.
The home had improved since the previous inspection. People told inspectors they felt safe and spoke positively about staff. Risks were assessed, staffing levels were sufficient, safeguarding systems were in place and the home worked with outside professionals.
There were still important problems. Some medicines were not given at the prescribed times, and instructions for some as-needed medicines were incomplete. Care records were not always up to date or detailed enough. The checks used by the provider had not always led to the improvements needed.
The overall rating remains Requires Improvement. Safe improved from Inadequate to Requires Improvement, while Well-led remained Requires Improvement. The report says the home remained in breach of regulations about safe care and treatment and good governance.
People felt safe
People told inspectors they felt safe. Staff knew how to respond to safeguarding concerns, and accidents and incidents were reviewed.
“People felt safe living at the service.” from the report
Kind and respectful staff
People spoke positively about staff and said they were treated with dignity and respect. Inspectors saw that staff knew people well.
“People were supported by staff who knew them well and it was evident that positive relationships had been formed.” from the report
Enough staff
Inspectors found sufficient staff on duty and effective recruitment procedures.
“Sufficient numbers of staff were on duty to meet the needs of people.” from the report
Choice and partnership working
The home supported people to make choices and used outside professionals to help meet their needs.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Medicines were not always safe
seriousInformation about blood glucose monitoring differed for two people. Some medicines were not given at the prescribed times, and instructions for some as-needed medicines were incomplete.
“Information about how to safely administer as and when required medicines was either not always in place or did not contain enough information to ensure medicines were administered safely and only when needed.” from the report
Checks did not drive enough improvement
seriousThe home's audits and checks found some problems but did not always make sure they were corrected across the service. This included medicines, kitchen areas and care records.
“Governance systems had not been robust enough to drive improvement.” from the report
Care records were not always complete
needs fixingSome care planning documents did not contain current and detailed guidance about people's individual needs, monitoring and care.
“We identified that not all people's care planning documents contained up to date and detailed information and guidance to staff about people's specific care needs, how they were monitored and delivered.” from the report
Kitchen areas needed attention
needs fixingInspectors found problems with food storage and the cleanliness and management of small kitchen units. The registered manager took immediate action after this was raised.
“However, we identified that improvements needed to be made in relation to the storage and management of food; cleanliness and management of the small kitchen units around the service.” from the report
- 01What has been done to ensure medicines are given at the prescribed times?
- 02How are staff now told when and how to give as-needed medicines safely?
- 03How will you check that care plans are up to date and give staff enough detail about each person's needs?
- 04What changes have been made to food storage and the small kitchen areas since the inspection?
- 05What evidence can you show that the warning notice about medicines has been met?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 29 March 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2022
Rated Requires Improvement, with Safe rated Inadequate; inspectors found unsafe medicines management and weak risk records, although improvements had started.
Inspectors visited without notice on 13, 14 and 22 July 2022. They looked at records for 19 people, checked 11 people's medicines, observed staff practice and spoke with people, families and staff.
The most serious concerns were about medicines and monitoring risks. Two people with diabetes did not always receive medicines at the right time. Four people had not received prescribed medicines for at least three days because there was no stock. Records did not always show that people had been repositioned, given enough food and drink, or had blood sugar checks.
The home was rated Requires Improvement overall. Safe was rated Inadequate. Effective, Caring, Responsive and Well-led were all rated Requires Improvement. Inspectors found some kind and safe support, but care was not always personal, meaningful or reliably recorded.
Safeguarding systems
Staff had safeguarding training and knew how to respond to concerns. Accidents and incidents were recorded and reviewed.
“Staff had received safeguarding training and knew how to identify and respond to any incidents of concern.” from the report
Choice and consent
Inspectors saw staff offering day-to-day choices and asking for consent. Mental capacity assessments and best-interest decisions were completed where needed.
“We observed staff giving people choice over their day-to-day lives and asking consent before providing support.” from the report
Access to healthcare
Staff made referrals when people's needs changed and supported people to attend appointments with health professionals.
“People were supported to access appointment with health professionals such as GPs, dentists and the hospital.” from the report
Complaints handled
There was a complaints system, and records showed that complaints were investigated and acted upon.
“Records showed that any complaints made were investigated and acted upon appropriately.” from the report
Signs of improvement
The provider, manager and staff reported improvements since the new provider took over and the new manager started.
“There was an overall feeling of change for the better from people and family members we spoke with.” from the report
Medicines
seriousMedicines were not always given safely or on time. Some prescribed medicines were unavailable for at least three days, putting people's health at unnecessary risk.
“Some people's prescribed medicines were not in stock which meant they had not been administered for at least three days.” from the report
Risk records
seriousRecords did not consistently show that important care had happened, including repositioning, food and drink support, and blood sugar monitoring.
“Records were not always completed to show that re-positioning had taken place in line with their care plans.” from the report
Staff consistency
needs fixingMany staff were new or agency workers. Inspectors found that people’s needs were not always known and some people waited a long time for help.
“The combination of new staff and agency staff meant that people's needs were not always known.” from the report
Personal care
needs fixingPersonal hygiene records were incomplete, so inspectors could not be sure people received the care they needed. Feedback included concerns about how often some people received showers.
“Gaps identified in personal hygiene records meant we could be certain people were receiving support with their personal care needs when needed and wanted.” from the report
Weak oversight
seriousThe home's checks had found some problems, but they had not ensured that the necessary improvements were completed.
“Governance systems had not been robust enough to drive improvement.” from the report
- 01What has changed since the inspection to ensure diabetes medicines are given at the correct time?
- 02How do you now prevent prescribed medicines running out, and how quickly are missed doses identified and acted on?
- 03How are repositioning, food and drink, blood sugar checks and personal hygiene now recorded and checked?
- 04How many regular staff and agency staff are currently working in each unit, and how do new staff learn each person's needs and preferences?
- 05What activities and regular contact are provided for people who remain in their rooms?
This was the first inspection of the newly registered service and covered all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 31 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Florence Mill Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2022Requires improvementstayed Requires improvementSafe: InadequateWell-led: Requires improvement
- July 2021Requires improvementstayed Requires improvementSafe: InadequateWell-led: Requires improvement
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022
Registered with the Care Quality Commission on 7 February 2022.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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