Millbrook House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the provider was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a clear focus on delivering high quality care and was strongly committed to empowering people and promoting their independence. They spoke passionately about ensuring people continued to feel as though they were living in their own home. This approach underpinned the provider’s vision for person centred care and created an environment where people’s autonomy, comfort and individuality were prioritised.

Staff consistently knew people well, and promoted independence, choice, and support in the least restrictive way.

The provider had a positive culture, which was demonstrated by staff and management. Staff consistently told us they enjoyed working at the home. Comments included, “The culture is good within the team, and we all support one another.”

The provider demonstrated a positive listening culture by acting on feedback they had received and informing and updating people of any changes they made because of this. People and their relatives were consistently positive about their experiences of the provider and how the management and staff team were approachable and how they had developed positive relationships with them. Staff told us, “You can tell management care very much about the home, the residents and the staff and always strive for improvements”.

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

The registered manager had the skills, knowledge and credibility required to lead the service effectively. They demonstrated integrity, openness and honesty in their approach, which helped create a positive culture where staff felt supported and people received high‑quality care. Staff said “I feel valued as an employee and management always have time to talk to me if I need help or advice” And “Our management are all approachable,easy to talk to, very supportive to all of the staff. we feel valued, cared for and appreciated”. Relatives told us, “[registered manager] is very caring and supportive of our loved ones.” And Millbrook House management is “Very consistent, caring and passionate”.

Staff were familiar with Millbrook House’s values and were asked during supervision sessions how they put them into practice. This helped embed the service’s values in day-to-day practice and ensures staff delivered care which reflected the culture and expectations of the service. People and relatives were encouraged to provide feedback that showed this was taking place in practice.

The registered manager spoke with compassion for the people living at Millbrook House. They described how staff consistently adapted their approach as people’s needs change, ensuring support remained responsive, person‑centred and focused on what mattered most to everyone. They highlighted several examples where the team had taken initiative-taking steps to maintain people’s wellbeing and continuity of care, demonstrating a strong commitment to positive outcomes. People were empowered and actively encouraged to participate in monthly ‘resident forums’ in which they had the opportunity to share suggestions and ideas for improving the service. Actions taken from suggestions included; changes to activities and trips out that were based on people’s interest. This demonstrated a sustained and exceptional impact on outcomes for people.

The provider and management team spoke about staff in a positive and compassionate way, demonstrating genuine appreciation for their contribution. The provider developed a range of resource leaflets to support people’s understanding of topics such as ‘keeping well at home’ and ‘pressure area’ to support their care and wellbeing. Leaflets were available throughout the home for visitors, relatives and staff to access.

Staff told us there was a positive culture of mutual respect, recognition and strong team morale.

The visible presence of the provider and management team ensured the home was not only well led but also an inclusive and welcoming place for everyone. Staff spoke positively about the management team, and were happy and proud to work at Millbrook House, staff turnover was low. Comments included, “You can tell management care very much about the home, the residents and the staff and always strive ways to make life better for people- after all, this is people’s home”. This leadership fostered a culture of openness, trust and respect, where people, families and staff felt valued, supported and empowered.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a clear culture based on openness and transparency. People and their relatives told us they felt able to speak up to the provider if needed. Records showed complaints were dealt in line with the policy and compliments were shared with the staff team.

Staff knew how to raise concerns, including how to ‘whistleblow’ if needed and how to access support. Whistleblowing is the act of reporting wrongdoing, misconduct, or illegal activities within an organisation.

There were clear procedures for regular contact with staff and the management team. Staff told us they felt comfortable raising concerns, and when they did so, they felt listened to. One staff member told us, “Management team and provider are approachable and they listen.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt valued and respected by both the provider and the manager, they felt supported to give feedback and were treated equally, free from bullying or harassment. Staff told us, “You can tell management care very much about us as staff, we are listened to and feel included in how the service strives to improvement”.

The provider had a policy in place to ensure staff were treated fairly and had equal opportunities to learn and develop their roles within the organisation. There were fair recruitment processes in place, which helped to protect the rights of staff under the Equality Act. We observed staff working together and communicating effectively with each other during our visits.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had various audits in place to ensure they maintained strong oversight of the service. However, we identified some inconsistencies regarding MCA and consent/best interests, these had not been noted during previous audits. Despite this, the management team responded to the shortfalls immediately.

A regular programme of spot checks was in place to review the quality and safety of care delivery.

The provider had established a process of learning from events that had either put people and staff at risk of harm, or had caused them harm, to improve the service. Staff told us there were opportunities such as the daily ‘flash’ meetings and supervisions where any lessons learned were shared with them. Feedback provided to the registered manager during the inspection was also acted upon quickly, demonstrating their responsiveness and commitment to continuous improvement.

Throughout our inspection, the management team was motivated to learn and improve the service.

Policies and procedures underpinned working practices, and this was supported by training and ongoing monitoring.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked in partnership with a range of health and social care professionals and the local authority. Records showed this included people seeing GPs and community nurses.

Good, well established, links had been made with external professionals and local provider support groups. This enabled opportunities to network, share experiences and ideas of ways to develop Millbrook House.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Systems in place ensured accidents and incidents had lessons learnt completed, and these were shared with staff in a variety of ways such as daily ‘flash meetings’ and via the electronic system. Openness and transparency about safety was actively encouraged and embedded in the service. Staff told us, “Any accidents and incidents are shared in the flash meeting every morning and reported on resident’s notes”.

Staff supervisions were used as an opportunity to reflect on incidents that had occurred and consider what could be done differently. This approach supported a strong learning culture where staff were encouraged to reflect on practice, share insights and continuously improve the quality and safety of care.