Millcroft

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. 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 71 (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.

Leaders promoted a culture of listening, learning and improvement. Regular meetings were held and lessons learnt were discussed and shared. The registered manager told us, “Our approach to care is about our resident’s voice, as the home grows and evolves so do we, we never stand still”. They told us they used one to one meetings to incorporate the service’s values.

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 registered manager was experienced and knowledgeable. They knew people and staff well. The area director visited the service regularly and provided support the registered manager and staff.Staff told us they were supported and felt listened to. One staff member told us, “The manager is very nice. They treat everyone the same and encourages everyone to work as a team”.

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

Staff were confident about being able to speak up if they needed to and had access to the providers whistleblowing policy for guidance on how to raise concerns. The registered manager told us, “We remind staff during supervision and induction that they can raise concerns in multiple ways”.

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

Staff told us they were treated fairly. The registered manager showed empathy and understanding towards staff and their individual needs. They described measures they had put in place to support disabled staff. The provider had systems in place to support staff wellbeing.

The provider had clear governance systems in place which staff and leaders completed in line with the provider’s schedule. Action plans identified where improvements were needed and the actions taken to address these. However, audits and checks had not identified some of the shortfalls we found during our visit. Forexample, staff had not identified the housekeeping trolleys did not have a lockable space to keep chemicals stored safely to prevent people from accidently ingesting them and causing them harm. Medicines audits had not identified that records for people administering their own medication were not accurate and did not clearly reflect the amount of stock that was held at the service.

Despite this, we found no harm to people. We discussed our findings with the registered manager who was open to feedback and took immediate action to address the shortfalls.

The registered manager told us they had created ‘how to’ guides to support staff in completing specific tasks. They were aware of their legal obligations and notified The Care Quality Commission of events which had occurred in the service and to act in an open and transparent way

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

Staff and leaders worked with external agencies to help ensure people received the care they needed. People were supported to maintain links in their local community. They visited local shopping centres, pubs and other points of interest. The local community were welcomed to attend some of the activities and events organised by staff.

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 contribute to safe, effective practice and research. Governance systems were in place to check all areas of the service. Where leaders found shortfalls, action plans were created to address any findings and drive improvements. Systems were in place to ensure staff were informed of any changesor improvements needed. The provider was open to the feedback we gave and took prompt action to address any areas we discussed with them.

Staff and leaders established links with the wider community to achieve positive outcomes for people. The registered manager told us they worked in partnership with a local college offering work experience placements to students to support them into employment. As a result of the work undertaken with them the, the service had been invited to attend an award ceremony as an employer of choice for supporting students.