CQC report explained · a nursing home
What the CQC found at Millreed Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2020
Millreed Lodge Care Home was rated Good; inspectors found safe, kind and personalised care, with management improvements since the previous inspection.
This was an unannounced inspection over three days. The inspector spoke with a person living in the home, relatives, staff, the manager and a visiting healthcare professional. They also reviewed care plans, risk assessments, medicines records, staff recruitment files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, clean premises, suitable training, good food choices and appropriate healthcare support. They saw staff treating people with kindness, respect and dignity.
The overall rating had improved from Requires Improvement at the previous inspection. Responsive and Well-led had both improved to Good. The report says the provider's audits were more robust and that care plans, management and partnership working had improved.
Safe staffing
Inspectors saw enough staff available to provide timely care and found that recruitment checks were robust.
“We observed staff constantly interacting with people and there were enough staff available to ensure people received timely care.” from the report
Kind relationships
Staff were seen to know people well and support them in a respectful and caring way.
“It was clear staff had developed good relationships with people and their relatives and knew people well.” from the report
Personalised care
Care plans recorded people's preferences, abilities and independence, and staff understood how people wanted to be supported.
“Care plans continued to be person-centred and contained specific individual details about people and how they wanted to be supported.” from the report
Improved oversight
Management checks had become more established since the previous inspection and were being used to identify and address issues.
“Since our last inspection audits had been further embedded into practice and were more robust, thorough and effective.” from the report
Management transition
minorThe registered manager had left shortly before the inspection. The replacement manager was still completing the formal CQC registration process at the time.
“The registered manager of the service had left the home in November 2019 and the current manager was in the process of formally registering with CQC.” from the report
- 01Has the current manager completed registration with CQC, and who is legally responsible for the home now?
- 02How will you assess and review my relative's needs before admission and after any changes?
- 03How will you make sure my relative's food, drinks and dietary needs are recorded and followed?
- 04What activities would be suitable for my relative's interests, communication needs and independence?
- 05How will you involve our family in care plan reviews and tell us promptly about changes?
This was an unannounced inspection covering all five key questions, including the premises and care provided; the overall rating improved from Requires Improvement at the previous inspection. This explanation was written from the published report of 19 March 2020 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
Rated Requires Improvement; inspectors found major progress since the home was in special measures, but care records and leadership improvements still needed to be sustained.
Inspectors visited without warning on 16 January 2019. They observed care, spoke with people, a relative and staff, checked care and medicine records, reviewed staff files and training, and looked around the building.
The home was rated Good for safe, effective and caring care. Inspectors found enough staff, safe medicines, suitable training, good support with food and healthcare, and kind treatment that respected people's privacy and dignity.
The home was rated Requires Improvement for responsive care and well-led care. New care records were being introduced but were not finished, and inspectors wanted to see that improvements in management and care quality were maintained. The overall rating was Requires Improvement.
Safe medicines
Medicine records were well completed and medicines were stored and managed safely. Staff administering medicines had received training, with competency checks being extended to night staff.
“Medicine administration records (MARs) confirmed this; they were well completed, with codes used to explain if medicines had not been administered as prescribed.” from the report
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff being patient, compassionate and respectful, including when supporting people with personal care.
“There was a happy, relaxed atmosphere in the home. Staff were friendly and cheerful and we saw this had a positive effect on people.” from the report
Activities
Activities had improved and included individual and group sessions based on people's interests. Inspectors saw people enjoying music, games, painting and entertainment.
“The home employed an activity organiser who arranged individual and group activities planned around people's interests and what they wanted to do.” from the report
Food and healthcare
People had meal choices, homemade food and support with specialist diets. The home also arranged access to a range of healthcare professionals.
“People's nutritional needs were met and they had access to healthcare professionals.” from the report
Improved management systems
A new registered manager, deputy manager and additional senior responsibilities had strengthened the service. Audits and action plans showed that issues were being followed up.
“Effective systems were in place to assess, monitor and improve the quality of the service.” from the report
Care records were not finished
needs fixingNew care documentation was more personalised, but it had not yet been completed for everyone. Until this work is finished, records may not fully show each person's current needs and preferences.
“New care documentation was being implemented to ensure people's needs were fully reflected.” from the report
Dementia-friendly environment
minorThere was some pictorial signage, but inspectors found few aids to help people find their way around. They recommended seeking specialist guidance as part of the refurbishment plan.
“We identified more could be done to make the environment dementia friendly.” from the report
- 01How many people's care records have now been completed using the new documentation?
- 02How do you check that every care record remains up to date when someone's needs change?
- 03What action was taken on the fire safety work identified by the fire authority?
- 04How are you checking that the improvements made since the last inspection are being sustained?
- 05What changes have been made to help people living with dementia find their way around the home?
This was an unannounced inspection of the overall service, covering all five CQC questions and checking progress after the previous Inadequate inspection and special measures. This explanation was written from the published report of 12 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 Millreed Lodge Care Home
5 rated inspections over 4 years: the service has improved, from Inadequate to Good.
- March 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2019Requires improvementup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2018Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2016Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 23 March 2011.
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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At least 100 live-in carers within about an hour of Calderdale
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 £980 to £1,260 a week. 87 can care for a couple. 12 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.