CQC report explained · a nursing home
What the CQC found at Mill Lane Nursing and Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had risk assessments and staff had guidance to reduce risks such as falls, choking and pressure ulcers. Medicines were given as prescribed, and audits identified and addressed discrepancies.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- The manager and provider had audits and monitoring systems, sought people's views and used feedback to improve the service. A new manager was in post and was applying to register.
What inspectors found, July 2023
Rated Good in a focused inspection; inspectors found safe care and strong oversight, but management was changing and some records had gaps.
This was an unannounced focused inspection on 15 June 2023. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment, safety and management records.
Inspectors found systems to reduce abuse and manage risks. Staff were available, recruited safely and supported people with medicines as prescribed. The home was clean, visits had no restrictions, and accidents and incidents were reviewed for learning.
The home was rated Good overall, with Safe rated Good and Well-led rated Good. The other three questions were not inspected at this visit, so their previous ratings were used to calculate the overall rating. A serious incident had prompted the inspection, but its circumstances were not examined in this report.
Risk management
Care records included assessments and guidance for important risks. Inspectors observed staff supporting people to move safely.
“People's care records included risk assessments which guided staff in how the assessed risks were to be mitigated.” from the report
Staff availability
Inspectors saw staff respond promptly to requests for help. Relatives said there were enough staff to meet people's needs.
“During our inspection we saw staff were available to attend to people's requests for assistance promptly, this included call bells.” from the report
Medicines
People received their medicines as prescribed. Monitoring and audits were used to find and address problems.
“People received their medicines as prescribed. Protocols provided guidance for staff to follow when administering, as required (PRN) medicines.” from the report
Learning from incidents
Accidents and incidents were recorded and reviewed for patterns. The home put actions in place to reduce future risks.
“Incidents and accidents were recorded, monitored by the manager and analysed.” from the report
People's involvement
People and relatives could share their views through complaints, surveys, compliments and meetings. Feedback was used to make improvements.
“People and relatives had the opportunity to share their views about the service in complaints, compliments, surveys and meetings.” from the report
Manager registration
needs fixingThere was no registered manager at the inspection. A new manager had been in post for 10 weeks and was applying to register.
“At the time of our inspection there was not a registered manager in post.” from the report
Care records
needs fixingRecords showing the administration of creams had gaps. The records improved after the manager intervened.
“The manager had identified records of the administration of creams had gaps, once they had intervened, the records had improved.” from the report
Communication
minorOne staff member said communication from management could be improved so that staff received the same messages about changes.
“However, another staff member said they felt communication from management could be improved, to ensure all staff received the same messages about changes made.” from the report
- 01Has the new manager's application to register with CQC been completed, and who is overseeing the home until then?
- 02How are cream administration records checked now, and have any further gaps been found?
- 03What changes have been made to ensure all staff receive the same information from management?
- 04What is the current position of CQC's further investigation into the serious incident mentioned in the report?
- 05How many agency staff are currently being used, and how are regular staff being maintained for consistency?
This was an unannounced focused inspection of Safe and Well-led only; the other three ratings were carried over from the previous inspection published in 2019. This explanation was written from the published report of 5 July 2023 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, February 2019
Mill Lane Nursing and Residential Home was rated Good; inspectors found safe, caring and well-managed care with no serious risks identified.
This was an unannounced comprehensive inspection on 21 January 2019. One inspector spoke with people, relatives and staff, observed care, and checked care, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were safe, their medicines and risks were managed, and staff were trained and available.
People were treated with kindness and respect. Their care was personalised, they had access to activities and health professionals, and complaints were investigated. The home also had systems to monitor quality and make improvements.
The overall Good rating was unchanged from the previous inspection in July 2016. Inspectors found no evidence or information showing serious risks or concerns.
Managing risks
The home assessed risks such as falls, pressure ulcers and mobility, and gave staff guidance on reducing them.
“People continued to receive a safe service. There were systems in place designed to reduce the risks of abuse and avoidable harm.” from the report
Food and health support
People could choose meals and receive support for dietary needs, hydration and choking risks. Health professionals were involved when needed.
“People's nutritional needs were assessed and met.” from the report
Kind and respectful care
Inspectors saw positive relationships and found that staff respected privacy, dignity, independence and personal choices.
“There was a relaxed and friendly atmosphere in the service and people and staff shared positive relationships.” from the report
Personalised activities
Activities reflected people's interests and included group events, outings and one-to-one time for people who stayed in their rooms.
“There was an activities coordinator who ensured activities were provided which matched people's interests.” from the report
Quality oversight
The management team used audits, feedback and meetings to identify shortfalls and improve the service.
“There continued to be a programme of audits which were used to monitor the service provided.” from the report
Inspectors raised no specific concerns in this report.
- 01How many regular staff currently work here, and how often are agency staff used now?
- 02How would you meet my relative's specific nursing, dementia, mobility or pressure ulcer needs?
- 03How are changes in a person's needs recorded and shared with all staff?
- 04What activities would be suitable for my relative, including if they prefer to stay in their room?
- 05How would you involve my relative and our family in end-of-life decisions and care planning?
This was an unannounced comprehensive inspection covering all five key questions, and the ratings remained Good from the previous inspection in July 2016. This explanation was written from the published report of 14 February 2019 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 Mill Lane Nursing and Residential Home
4 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- July 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Mill Lane Nursing and Residential Home →
- February 2019Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Mill Lane Nursing and Residential Home →
- August 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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