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Mill River Lodge Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 7 April 2020

About the service

Mill River Lodge is situated in Horsham, West Sussex and is one of a group of homes owned by a national provider, Shaw Healthcare Limited. It is a residential ‘care home’ for up to 70 people some of whom are living with dementia, physical disabilities, older age and frailty and may need support with their nursing needs. At the time of the inspection there were 62 people living in the home.

People’s experience of using this service and what we found

Newly implemented systems and processes had helped decrease risks to people’s care. These were yet to be fully embedded and sustained in practice to ensure there was enough oversight of all people’s care. There was a lack of guidance to inform staff of some people’s preferences and needs and some people had not been supported according to their assessed needs. Audits had not always identified the shortfalls that were found at the inspection.

Lessons had not always been learned when incidents had occurred. Since the last inspection, outcomes from the local authorities safeguarding enquiries as well as our own, had sometimes found people had not received safe care and treatment.

There was a lack of oversight to ensure all agency staff were assessed as competent before they started to support people and we found three occasions when agency staff had not ensured people’s needs were met. Two people had not always been consistently supported with their oral hygiene. Two people’s emotional needs had not been fully considered.

We recommended that the provider continued to ensure all people who required assistance with communication were provided with information that was accessible to them.

There were enough staff to meet people’s needs. Staff had received appropriate learning and development opportunities to meet people’s needs and knew how to minimise the risk of abuse. People told us they felt safe and were happy at the home. Most risks in relation to people’s care were managed well. Medicines management was safe. Infection prevention and control was maintained.

People told us they enjoyed the food and had enough to eat and drink. People received support from external health professionals when needed and staff worked with them to ensure a coordinated approach to people’s care. Changes and improvements had been made to the environment to ensure it met all people’s 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; the policies and systems in the service supported this practice.

A new manager was in post who had been instrumental in making improvements to people’s care and ensuring that risks decreased. The provider and manager had worked with external health and social care professionals to seek advice and guidance.

The manager and staff placed an emphasis on providing more person-centred care for people and ensuring that people had access to stimulation and activities that were meaningful. People told us they had access to a range of activities, and they enjoyed those provided. If people were unhappy with their care, they and their relatives told us they felt comfortable raising concerns with staff. People were able to plan for care at the end of their lives to ensure their preferences were known and their comfort maintained.

People told us staff were kind, caring and compassionate and our observations confirmed this. People were encouraged to be involved in their care and in decisions relating to it. Independence was promoted and people were able to retain their skills. When people did require assistance their privacy and dignity was maintained.

Rating at last inspection and update

The last rating for this home was Requires Improvement (Supplementary inspection report published 14 September 2019). There were three breaches of regulation in relation to people’s safety, person-centred care and the leadership and management of the ho

Inspection areas


Requires improvement

Updated 7 April 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 7 April 2020

The service was not always effective.

Details are in our effective findings below.



Updated 7 April 2020

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 7 April 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 7 April 2020

The service was not always well-led.

Details are in our well-led findings below.