CQC report explained · a nursing home
What the CQC found at Mildenhall Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, safeguarding concerns were reported appropriately, medicines were managed safely and infection controls were in place. They recommended close monitoring of staffing levels because feedback about staff availability was mixed.
- Effective?
- Good
- This key question was not rated in this report.
- Caring?
- Good
- This key question was not rated in this report.
- Responsive?
- Good
- Care plans were detailed and person-centred. People could make choices about their routines, communication and activities, and the home had systems for handling complaints and planning end of life care.
- Well-led?
- Good
- The home had quality checks, audits and systems for acting on feedback. However, some staff reported mixed morale during management changes, and some relatives felt the manager was less visible than the previous manager.
What inspectors found, November 2022
Rated Good; inspectors found safe, personalised care, but staffing levels needed close monitoring.
This was an unannounced inspection on 5 and 11 October 2022. Inspectors spoke with people living in the home, relatives and staff. They also observed care and checked care plans, medicines records, recruitment files, audits and maintenance records.
The home had systems to manage risks, medicines, infection control, safeguarding, complaints and accidents. Care plans were detailed and personal. People had choices about their daily routines and activities, and staff supported their individual interests.
Feedback about staffing was mixed. Some people and staff said they sometimes had to wait for help, especially at night or on two suites. Inspectors recommended that staffing levels continue to be monitored closely. The overall rating was Good. Safe stayed Good, while Responsive and Well-led changed from Outstanding at the previous inspection to Good.
Personalised care
Care plans gave staff information about people's needs and preferences. Inspectors saw that staff responded to people as individuals and updated records when needs changed.
“Care plans were detailed and person-centred. They contained sufficient information to enable staff to support people and understand their preferences.” from the report
Activities and relationships
People were offered activities and opportunities based on their interests. The lifestyle team helped turn some people's wishes into experiences.
“The provider employed a 'lifestyle team' who worked together well to ensure people had opportunities to take part in favourite pastimes and new experiences.” from the report
Medicines and infection control
Inspectors found that medicines were stored, administered and recorded safely. The home also had effective arrangements for preventing and managing infection.
“Medicines were stored and disposed of safely. Medication Administration Records (MAR) showed people received their medicines as prescribed and these records were completed accurately.” from the report
Quality checks
Managers carried out audits and other checks to monitor care and make improvements. People, relatives and staff were given opportunities to share their views.
“The registered manager and management team carried out a range of checks and audits to monitor and improve the quality of the care and support people received.” from the report
Staffing availability
needs fixingSome people and staff said there were not always enough staff, with particular concerns about waiting for help at night and pressure on two suites. Inspectors recommended continued close monitoring of staffing levels.
“We received a mixed response from people regarding the availability and timeliness of staff in meeting their care needs.” from the report
Staff morale and management visibility
minorSeveral management changes had affected staff morale for some workers. Some relatives also said the manager was not as visible in the home as the previous manager.
“The majority of the management team were new in post and coupled with some other management changes, several staff reported mixed morale as an impact of this.” from the report
- 01How many staff are planned for each suite during the day and at night, and what happens if someone does not attend their shift?
- 02How are waiting times for call bells, toileting and night-time support monitored?
- 03What action is being taken about the staffing and skill-mix concerns raised by staff?
- 04How often will the manager meet residents and relatives, and how can families raise concerns directly?
- 05What changes have been made to the menus following residents' complaints about food?
This was an unannounced inspection looking at Safe, Responsive and Well-led; Effective and Caring were not rated in this report, and the previous ratings for Responsive and Well-led had been Outstanding. This explanation was written from the published report of 17 November 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.
What inspectors found, January 2018
Rated Outstanding; inspectors found kind, safe and effective care, with especially strong personalised support and leadership.
Inspectors visited the home without notice on 15 November 2017. They spoke with people living there, relatives, staff and managers. They reviewed care records, medicines records, recruitment files, training records and quality checks.
The home was rated Good for Safe, Effective and Caring. Inspectors found enough staff, safe medicines arrangements, suitable training, prompt healthcare support, sufficient food and drink, and kind and respectful care.
Responsive and Well-led were rated Outstanding. Inspectors found care was highly personalised, people's views shaped decisions, activities met individual interests, and complaints were investigated. They also found strong leadership, detailed monitoring and a clear focus on improvement.
The overall rating changed from Good at the previous inspection in February 2016 to Outstanding. The report says significant improvements had been made, particularly in Responsive and Well-led.
Personalised care
Care plans reflected people's individual needs and preferences. Relatives were involved, especially when people living with dementia needed support to express their views.
“People were receiving an exceptionally person centred service.” from the report
People's voices
People were asked to help make decisions about the home, including activities, meals and events. Their feedback was recorded and used to make changes.
“People's views and opinions were actively sought throughout all aspects of their home and listened to and action taken in response.” from the report
Activities and community links
The home offered varied activities, trips and opportunities to stay in contact with family and the local community. Inspectors saw several social areas and activities shaped around people's interests.
“Social inclusion was an important part of day to day life at the home.” from the report
Strong leadership
The registered manager had a clear vision and used detailed checks to monitor quality and identify improvements. Staff said they felt valued, supported and involved.
“There was a strong emphasis on continual improvement and best practice.” from the report
Life story records not all complete
minorDuring a dementia care audit, staff said 75% of life story books were fully completed. The report praised these records but did not say that all were finished.
“We've got 75% fully completed so far. The life story books are so important as it enables staff to get to know people better” from the report
- 01How many people's life story books are fully completed now, and how are they used in daily care?
- 02How do you maintain staffing levels when staff are off sick or on leave?
- 03How will you make sure activities continue to reflect my relative's interests and choices?
- 04How are relatives involved in reviewing care plans, particularly for people living with dementia?
- 05How do you use complaints, meetings and feedback to make changes?
This was an unannounced inspection of the whole service, covering all five CQC questions and the overall rating. This explanation was written from the published report of 24 January 2018 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 Mildenhall Lodge
4 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingdown from OutstandingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Outstandingup from GoodSafe: GoodResponsive: OutstandingWell-led: Outstanding
- April 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- September 2014
Report published without a new overall rating.
- June 2014
Registered with the Care Quality Commission on 16 June 2014.
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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23 live-in carers within about an hour of Suffolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
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