Archived: Milestone 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 requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service and notifying CQC of important events.

This service scored 36 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people. Registered persons had consistently failed to make improvements to the service to improve people’s lives. The service had been in breach of regulations for 5 consecutive inspections. This evidenced that the provider did not respect people and their rights. The staff gave mixed feedback about the culture of the service. Some staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Other staff gave negative feedback. Comments included, “I don’t [raise concerns] because nothing is confidential”; “I don’t feel I can talk to [manager]; I am nervous around [them]”; “The staff are divided between the night staff and the day staff. The night staff are overlooked”; “It’s not a team, it’s really weird” “The culture was not so good, but it has improved a bit. Some days there is tension, we are encouraged to talk to each other to work it out” and “There are good days and bad days. The staff are okay they are a good group, but they can get down.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The registered manager had only been to the service 8 times in 2025 and had not been present as a leader. Records the registered manager showed us evidenced they had only been to the service 3 times in December 2024, 3 times in November 2024, 3 times in October 2024, 5 times in September 2024, 3 times in August 2024, 9 times in July 2024 and 5 times in June 2024. The registered manager and provider had no oversight of day-to-day operations, had not been attending staff meetings and had not been carrying out audits and checks. Staff did not know when the registered manager would be attending the service, the registered manager was not included on the staff roster. Since 25 February 2025 the registered manager had not been available on the telephone due to a medical condition. They told us they contacted the manager and administrator daily by text or email and they told us they had an electronic tablet which converts voice to text. They did not attend the assessment site visit on 28 and 29 May 2025 despite having this equipment in place.

Staff told us they had not seen the registered manager for a long time. A staff member told us, “The registered manager is not at the service very often. He can’t hear properly in the last 3 weeks; in the last 6 months he has not been here very much.” Another staff member said, “The only monitoring [registered manager] does is he only reviews CCTV, he does it from home. He monitors for staff sitting down. He will call and speak to staff or will ask [the administrator] to speak to staff.”

The registered manager had not kept up to date with best practice by completing training, reviewing information from CQC and attending meetings held by the local authority or health and social care organisations.

People did not always feel they could speak up and that their voice would be heard. Staff confirmed they were invited to meetings and encouraged to contribute. However, they did not always feel listened to. A staff member said, “Sometimes have a staff meeting every 6 months, [the manager] talks and makes notes, but nothing ever comes of things.” Some staff told us they were encouraged to voice their ideas for improvements and any concerns. The provider had a whistle blowing policy in place. However, we received mixed feedback from staff about how to raise concerns with the provider or outside organisations if they needed to. Some staff said they don’t feel listened to and would not raise concerns. A member of staff said, “I haven’t had to whistle blow, yes I would be okay to do this."

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.Staff across the service were supported where necessary with reasonable adjustments in relation to their personal/health needs such as changes to shift patterns to support childcare arrangements. However, staff told us that the workforce was treated differently by the provider. Staff told us they were not allowed to park their vehicles in the car park of the service, which made it difficult when the weather was bad and meant that staff had to walk in the dark when they finished their shifts to go home. A staff member said, “He does not allow staff to park in the car park. Night staff only are allowed to park.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We served the provider a warning notice at the last inspection which had been ignored. We asked the provider (who is also the registered manager) why they had not met the warning notice, and they did not respond. The provider had sent an action plan after the last inspection to detail how they would meet the other breaches of regulations. However, there had not been provider oversight to check actions had been achieved, embedded and that regulations were met and continued to be met. There was continued breaches of regulations found at this inspection. We found that records were inconsistent in places. For example, fluid records did not always show that people had drank enough to remain healthy. Actions from own the managers audits undertaken had not been addressed by registered persons in a timely manner. For example, worn carpets repeatedly appearing in infection control audits had not been sorted it. We raised issues with the carpets at the last inspection in 2023. We found audits were not always robust; care plan audits did not pick up on the issues we found during our assessment.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We found that the provider had failed to tell CQC about deprivation of liberty safeguards (DoLS) authorisations. After the assessment visit the manager submitted these in retrospect. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. All staff worked with visiting health and social care professionals. Staff explained how they welcomed visitors. We observed some people were supported to get out into the community to access day services, a person was supported to go to the hairdressers. However, we observed there was not much structure around this. Daily records did not evidence that activities to meet people’s needs, particularly their sensory needs, were taking place in the service or in the community. Some staff told us people were not going to day services and some staff told us they were going. One of the local authorities who commissions services for people told us, ‘I have had ongoing contact with [the manager] at the service and she works with us well, she is responsive but also calls to discuss matters and take advice. We have recently liaised regarding personal allowances/finances for residents including one out of area resident. We have not had significant contact with [name] the registered manager except to discuss fees and referrals.’

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Since our last inspection there had been no improvement in the service. Any improvements the provider stated they had made within their action plan had not been robust. The provider had not learnt from previous inspections and had not sought support and guidance from organisations and the local authority provider forums to drive improvements. Since we carried out the assessment of the service, the manager at the service has made some changes to address some of the issues.