Florence Mill Care Home

Updated 29 March 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The first day of the inspection was carried out by 4 inspectors and an Expert by Experience; 2 of these inspectors returned on the second day. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Florence Mill Care Home is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Florence Mill Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced on both days.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 27 people who used the service and 6 family members about their experience of the care provided. We also observed interactions between staff and people who used the service. We spoke with 15 members of staff including the registered manager, nominated individual, ancillary staff, nurses and carers. We reviewed a range of records. This included people's care records and medication records. We looked at a selection of staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed. The provider and registered manager continued to submit information about the service following our two visits to the service.

Updated 29 March 2024

About the service

Florence Mill provides nursing and/or personal care for up to 150 older adults, some of whom were living with dementia, across four individual single-story units. At the time of our inspection 122 people were living in the home.

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

People's medicines were not always managed safely. We found that improvements had been made since the previous inspection however, further improvements were identified in relation to the safe management of people’s medicines.

Whilst governance systems had been effective at identifying areas of improvements needed, they had not always been robust enough to make the necessary improvements required. The provider and registered manager recognised the need for improvements to be made and continued to make changes.

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.

People told us they felt safe living at the service. Clear procedures were in place for the reporting of incidents, accidents and safeguarding concerns to prevent further occurrences.

People spoke positively about the support they received from the staff team and that they were treated with dignity and respect. Effective procedures were in place for the safe recruitment of staff.

Risks to people's health and wellbeing had been assessed and guidance was available for staff to support people safely. Regular checks and maintenance of the service took place to provide a safe environment for people to live.

Staff felt supported in their role and regular meetings took place to share information and opinions about the service. The service worked in partnership with other external agencies and professionals to promote and meet the needs of people living at Florence Mill.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 31 August 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, although improvements had been made, we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 31 August 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Florence Mill Care Home on our website at www.cqc.org.uk.

We have identified breaches in relation to medicines management and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.