- Care home
Mill View Care Home
Assessment report published 13 April 2026
Contents
Ratings
Our view of the service
Date of assessment: 18 to 24 February 2026. This assessment was completed to follow up on our previous inspection when we rated the location requires improvement and we identified 3 breaches of legal regulation. At this inspection we identified continued breaches of regulation regarding safe care and treatment, person-centred care and good governance.
Although some positive staff practice was observed, people did not consistently receive safe, responsive or well-led care. Shortfalls in staffing, care planning, day -to -day organisation and the oversight of quality and risk meant improvements were required to ensure people experienced care that met their needs and promoted their wellbeing.
People told us most staff were kind, but felt staffing levels were not always sufficient to ensure people received timely support; this was supported by our observations. At busy times, people experienced delays in receiving assistance with personal care, meals support or mobility support.
Risk assessments and care records were not always accurate or up to date. We found examples where people’s current health needs, risks or mobility levels were not clearly reflected in their care plans. This meant staff did not always have the information required to support people safely. People also reported delays in staff responding to requests for help, particularly during peak periods, which affected their sense of safety and security.
The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. This placed people at risk of not receiving their medicines as prescribed.
People told us there were no structured or meaningful activities in place, leaving many people without stimulation or opportunities to engage in social or recreational experiences; this contributed to feelings of boredom and isolation. Staff told us the lack of activities was due to limited time and staffing pressures. Leadership and governance arrangements were not fully effective. While leaders were committed to improving the service, oversight systems were not robust enough to identify and address recurring issues in care quality, record keeping, staffing, or activities provision. Audits were carried out, but they did not always lead to sustained improvements.
Staff told us they did not always feel supported and felt the home lacked clear direction at times. Communication among staff teams was also variable, which affected continuity of care.
Although some improvements had been initiated, leadership had not consistently ensured people received safe, personalised and well organised care.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People did not consistently receive a positive experience of care. While people expressed general satisfaction with their care, we found elements of care did not meet the expected standards. Although some people and relatives told us staff were kind and tried their best, the quality of people’s daily experience varied. People told us they sometimes had to wait for support, particularly at busy times, and some people and relatives felt staff were often rushed and unable to spend meaningful time with them, despite their best efforts.
People told us information was not always communicated in a clear or timely way. People did not always feel their independence was consistently promoted. We observed instances where staff supported people in a task focused manner rather than taking time to understand people’s individual preferences. Some people told us they felt their choices such as preferred routines or activities were not always respected. People were not always involved in decisions about their care, and information in care plans was not consistently accurate or up to date.
Feedback about safety was mixed. While some people told us they felt safe, others said they were worried about the lack of staff and the use of agency workers who were unfamiliar with their needs. Although some positive relationships between staff and people were evident, the provider did not always ensure a consistently caring and person-centred approach. People told us improvements were needed in communication, staffing levels, and how well staff understood and respected their individual needs.
Most people told us they were happy with safety related to the care provided. However, all relatives and some people said staffing levels could be improved, and some people did not feel safe. A person told us, “I don’t feel totally safe as I have had a lot of things taken from my room. One night I was in bed, and a lady tried to get in bed with me. I have told the staff, but they say they can’t do anything to stop it happening.” On many occasions we saw there was minimal interaction between staff and people. Although some interactions we witnessed were patient and kind, most interactions were task led as staff were busy.
People’s social and recreational needs were not always being met. People and relatives told us there were no meaningful individual activities on offer, which we observed, and no meaningful planned activities on all houses. Relatives also told us about unexplained falls, lack of staff, people’s hobbies and interests not being accommodated, and items of clothing regularly going missing. We observed long periods of time when people had nothing to do, and there were no structured or meaningful activities available to support their wellbeing. People told us they felt bored or isolated, and staff confirmed activities were not routinely delivered due to staffing pressures.
Although there were positive comments about individual staff members, the provider did not ensure a consistently caring or person-centred approach. People said improvements were needed in communication, ensuring care plans were accurate, and providing meaningful activities to support their wellbeing.