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Mildenhall Lodge Outstanding

All reports

Inspection report

Date of Inspection: 31 July 2014
Date of Publication: 17 September 2014
Inspection Report published 17 September 2014 PDF


Inspection carried out on 31 July 2014

During a routine inspection

During our inspection we spoke with eight people who used the service, three relatives, seven members of staff and the registered manager. We carried out a structured observation and observed staff providing care and support on all three units. Other records we reviewed included staff files and quality and monitoring records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

Care records were not always updated to ensure that people received the care they needed to keep them safe. We found some records which were not completed appropriately and contained conflicting information which placed people at risk. Some records were not sufficiently detailed to ensure that staff had all the information they needed to keep people safe.

The service worked with other healthcare professionals to help meet people�s healthcare needs.

We saw that regular checks were carried out on the fire equipment and systems. However we found that the call bell system was not operating correctly throughout the service and this posed a risk to people who used the service.

We observed how staff provided care and support and looked at staffing rotas. We found that there were not always enough trained and experienced staff on duty to meet people�s needs and ensure their safety.

We found that the service was aware of their responsibilities under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and most staff had received training. We saw that the service had made a DoLS application for one person and was considering making two further applications. This meant that the service was taking steps to ensure that people were kept safe and not unlawfully deprived of their liberty.

Is the service effective?

People�s care and support needs were assessed in consultation with either the person themselves or relatives. Most people�s care plans reflected their care and support needs although we found that some plans did not identify in enough detail how their needs should be met.

We found that care plans to monitor and manage people�s diabetes were not specific and management of people�s diabetes was not effective.

We were concerned that a lot of people seemed to be spending the majority of their time in their rooms. One person told us, �There�s not much to do. The food is very good. I eat my meals in my room�.

Is the service caring?

People were supported by staff who were caring and respectful. We observed staff engaging positively and warmly with people.

People who used the service and their relatives told us that they found the staff very caring. One person told us, �I wasn�t feeling very well yesterday and they looked after me lovely�. Another person said, �[My relative] likes to look after [their] appearance. I find [they] always look nice�.

Is the service responsive?

Low staffing levels on the day of our inspection meant that people did not always get the help and support they needed promptly. People who used the service told us that although they were happy with the staff they struggled to find them at times. One person who used the service told us, �The staff work hard but you have to be patient. It does take them some time to answer your call bell�. We found that call bells were not always answered promptly.

Records showed that where concerns about an individual�s wellbeing had been identified, staff had not always taken appropriate action to ensure that people were provided with the support they needed.

Is the service well led?

We were concerned that despite the fact that the service had only been operating for a number of weeks we were able to identify a number of issues which required improvement.

Systems to assess staffing levels and review and monitor care plans were not robust. We were concerned that the service had not identified yet how to audit the response times to the call bells. When they did learn how to gather this information following a request from us it highlighted that some call bells had not been answered within an acceptable timeframe.