Millies Care and Support Agency Limited

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.

The service was in breach of legal regulation in relation to Governance.

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.

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 and their communities.

The provider did not have a clearly defined statement or vision and strategy that detailed their goals and objectives. This was not clearly detailed in the provider’s statement of purpose. However, most staff told us the provider’s mission statement was to “Provide quality care” and “Respect everyone with kindness and dignity.”

The provider did not always act to address and improve in areas of care where people had raised concern. For example, several people told us they had to contact the office numerous times regarding late visits, yet staff were still late. Further, there were no lessons learnt from several safeguarding concerns raised. Managers confirmed they had not debriefed or discussed this as a learning exercise with other staff.

This meant concerns were not always acted on or resolved, reducing people’s confidence in the provider’s ability to listen and respond effectively. It also limited opportunities for improving culture through learning and improvement, which could impact the overall quality and experience of care for people.

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. Managers lead with integrity, openness and honesty.

However, managers did not always have the skills, knowledge, experience and credibility to lead effectively.

Managers knew the people they supported well and were working towards advanced qualifications to further develop their skills and improve the quality of the service.

We found the registered managers to be open and honest about the challenges they had experienced while transitioning from a paper-based system to an electronic records system. They recognised there were gaps in documentation and demonstrated a clear willingness to address these and make improvements.

Staff told us the service was “well managed,” but some said it could be more organised, explaining, “We all do a bit of everything, sometimes we don’t know who is doing what.” We raised this with the provider who agreed they would spend some time looking at the structure and duties of all staff.

Despite this, people receiving a service gave positive feedback. Comments included “I only have occasional involvement with management and office staff,” and “They are there when I need them via phone.” People also told us, “I think the agency is run well overall by inclusive leaders,” and “I would recommend Millie’s Care and Support Agency Limited, definitely.”

This meant the leadership team had a good understanding of the service and showed a proactive commitment to learning and development. However, records did not demonstrate that oversight was consistent, which limited the service’s ability to identify and address issues in a timely manner.

The provider fostered a positive culture in which people felt able to speak up and confident that their voice would be heard.

Staff told us they felt comfortable raising concerns and expressing their views. One member of staff said, “I say what I want anyway. If something isn’t right, I say it. You never feel judged.” Although staff were not familiar with the term Freedom to Speak Up, and the registered location did not have any speak up documentation on view, staff they understood how to raise issues and felt supported when doing so.

During the inspection, we saw staff were given opportunities to share concerns or suggestions during supervisions, and an anonymous feedback box was available in the office to encourage open communication. This meant staff felt confident to raise concerns and were assured their views would be taken seriously. Managers confirmed people and staff were encouraged to share their experiences of care.

The provider valued diversity within their workforce and actively promoted an inclusive and fair culture. They demonstrated a commitment to improving equality and equity for the people who worked for them.

Workforce equality, diversity and inclusion (EDI) policies were in place, and staff told us they had not experienced any discrimination. Staff were positive about the provider’s approach to EDI.

There was evidence staff completed a health questionnaire when they commenced their role. At the time of the inspection one staff required support with reasonable adjustments. This meant the provider fostered an inclusive and supportive working environment where staff felt valued, treated fairly and able to access reasonable adjustments when needed.

Managers confirmed this and told us they treated staff and people as individuals, with staff commenting “We feel listened to and encouraged to speak up in meetings and share ideas.”

This meant staff experienced workplace equality where their views were respected, their individuality was recognised, and their contributions were encouraged. This helped to promote an environment that supported equity, inclusion and positive working relationships across the team.

The provider did not have clear responsibilities, defined roles or effective systems of accountability, and governance arrangements were not functioning well. Leaders did not consistently act on the best available information about risk, performance or outcomes, and they did not reliably share information securely with others when appropriate.

There were significant gaps in audit and oversight processes, limiting the provider’s ability to identify issues, drive improvement and ensure staff had access to up-to-date information. For example, the provider’s medication policy stated competency assessments should be refreshed annually. The provider had not ensured this had been consistently completed. Following our inspection, the provider confirmed staff were now allocated annual refresher training

In addition, the provider had not implemented an effective system to track whether people received early, late or missed visits, or whether staff remained for the full duration of scheduled calls. This meant the provider lacked a reliable overview of service performance and the quality of care being delivered. As a result, the provider did not identify emerging concerns, ensure staff competence, or implement timely improvements to maintain people’s safety and wellbeing.

Managers told us they always tried to ensure people received their care on time and spoke about a number of issues which could affect timely care such as traffic. However, the provider could not demonstrate these factors had been taken into account nor did they have a plan for addressing these shortfalls.

The provider understood the need to work in partnership with others, helping services to operate more seamlessly for people. They shared information with external partners and engaged in joint working to support ongoing improvement.

We saw evidence of effective partnership working with other professionals involved in people’s care, including occupational therapists and doctors. For example, staff had shared relevant information about a person experiencing cognitive decline, and a referral had been made to the memory clinic. Where people had been assessed as needing support to access the community as part of their care plan, staff helped people to attend meaningful activities. This meant people benefited from more coordinated, joined up care, with timely referrals and shared information helping to ensure people’s needs were recognised and responded to.

However, there was no evidence to demonstrate the provider had undertaken any form of quality assurance or engaged external partners to help identify areas requiring improvement. This meant the provider was not proactively using external resources or standards to strengthen quality and compliance systems which limited opportunities to address shortfalls, recognise gaps, drive improvements or ensure sustained oversight of service performance.

The provider did not always focus on continuous learning, innovation or improvement across the organisation. They did not consistently encourage creative approaches to delivering equality of experience, outcomes or quality of life for people. In addition, the provider did not always contribute actively to safe, effective practice or wider sector learning.

People said they felt able to share their views and raise concerns, and staff told us they were encouraged to speak openly about issues or suggestions for improvement. Comments included, “We feel listened to and encouraged to speak up in meetings and share ideas.” However, people also told us that some ongoing issues, such as late visits, had been raised repeatedly without consistent improvement, which meant they were not always confident that learning led to meaningful change.

We saw the provider recognised the need to strengthen organisational systems to support continuous improvement. For example, leaders were planning to introduce formal team meetings with structured agendas to create more opportunities for staff learning and discussion, but these had not yet been implemented. We also saw lessons from safeguarding concerns had not been consistently captured or discussed, which limited the provider’s ability to learn from incidents and drive improvement across the service.

Managers confirmed they were working to improve record‑keeping and oversight arrangements, acknowledging gaps in documentation and the need for better systems to embed learning. They told us they were transitioning from paper to electronic systems and were committed to improving quality. However, they had not yet implemented consistent processes to review incidents, share learning or monitor improvement actions.

This meant that although staff felt listened to and leaders demonstrated willingness to improve, learning was not yet embedded across the service. Opportunities to innovate, reflect and drive sustained improvement were missed because systems for reviewing performance and sharing learning were not fully established or consistently applied.