Millreed Lodge Care Home

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 changed to requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they had not always do so with integrity, openness and honesty.

The provider had experienced recent problems with stability of management at the service. A long-standing manager had left, and the following manager also left after a short period of time. The deputy manager took on the management role during this period and staff were positive about the support the deputy provided. However, provider level oversite was not fully effective during this time, and they appeared to lack awareness of the impact some poor management had on the service. One member of staff told us they thought the provider and their management team could have been more proactive and supportive of the service during this time. A person living at the home told us, "I'm not sure who the manager is” and another said, "The manager didn’t stay very long.” A new experienced manager had been recruited and started in their role during this assessment. They were aware of improvements needed at the service and were working with the regional manager and deputy to formulate action plans to address this.

The management team were open, responsive and pro-active to the assessment process and demonstrated a commitment to making improvements at the service.

People did not always know who to speak to make sure their voice was heard.

People and relatives told us they felt able to speak to staff when they needed to, but some people were unsure about who the manager was and there was a lack of formal approach to gaining people’s views about the service.

The staff told us they were aware of the whistle blowing procedure and said recent changes in management had given them more confidence that any issues would be listened to.

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.

The provider had a diverse workforce in place. Staff felt supported and were confident in the fair approach of the management team.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Quality and safety audits were carried out by the management team at various intervals. However, audits had failed to identify issues in relation to matters including care documentation, medicines management, consent and best interest decision process.

There was a governance and auditing structure in place, but this was being reviewed and strengthened as a result of issues identified in relation to previous management of the service. The new manager had an action plan in place and was working closely with the wider management team to make sure auditing was robust and effective.

We were assured that these improvements would ensure peoples care was monitored and improved when the need was identified.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The management team recognised that their systems for measuring quality had not supported continuous learning and improvement at the service. We were assured that the new governance systems would include analysis of audits to promote learning and improvement.