Millmoor Cottage

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.This is the first assessment for this service registered since August 2022. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 86 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.The leadership team encouraged transparency and welcomed feedback. Staff told us the purpose of the service and understood the organisation’s goals. Staff told us there was a very open and honest culture within the service and the organisation. During our visit we observed staff interactions with people, which were kind, caring and respectful. This showed staff demonstrated the values of the organisation. The provider showed an excellent understanding of the needs of people with learning disabilities and the challenges they may encounter. The provider made every effort to ensure people were supported to be part of their community in a meaningful way. For example, by exploring opportunities in education, employment and leisure pursuits. People’s wishes, preferences and aspirations were at the heart of their care and support. People were fully involved in design and delivery of care.

The provider had 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 did so with integrity, openness and honesty. The management team were present and available in the service. They understood the importance of leading from the front. They encouraged staff to be open and honest. Staff told us they felt very well supported by the management team. Staff were included in decision making about the service and organisation.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a system to enable people and staff to raise concerns at any level. There was a whistleblowing policy. Staff told us they could raise concerns, and they would be addressed.

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 could develop their skills and development plans were used. For example, one staff member was developing their managerial skills with support from the leadership team.

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

The provider had robust systems in place to check the quality of care. Audits were carried out on a regular basis covering all aspects of care delivery. Actions from audits were recorded and followed up in a cycle of audits, actions and outcomes. People and staff were updated on actions through regular meetings. The provider worked in a way which was proactive and preventative. Good governance has led to excellent outcomes for people, for example, people having a role in employment and gaining an education qualification.

Risks identified were shared with all relevant parties and measures put in place to mitigate these. The leadership team maintain excellent oversight of the service and ensure they keep on top of issues arising and actions taken. People benefit from this oversight as they can be confident their care is delivered in a way which is driven by robust risk management. In one care plan audit it showed a person needed a medical check up and this was arranged without delay.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.The provider worked in a collaborative way with the local authority and other health care professionals. They actively sought out activities within the local community to enable people to be as involved as they would like to be. For example, the local community benefited from people at the service contributing to the church through their baking skills.In addition, opportunities to participate in education and employment were identified and utilised. This led to excellent outcomes for people. The provider and local authority worked together to ensure a comprehensive and challenging transition was carried out leading to a successful placement for a person. It was clear people at the service benefited from this approach.

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. The provider had an extensive service improvement plan which included all actions that were either achieved or planned. For example, health and safety audits for hazardous substances were being reviewed at the time of our inspection. Additional work around healthy eating was planned for the near future. Overall, the provider was making sure all actions and plans were going to improve the service. Continuous learning was at the heart of the service improvement plan.