Mill View Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of legal regulation in relation to people’s safe care and treatment and medicines management. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although the providers’ auditing systems had identified numerous concerns, including some of the issues we noted during our assessment, these had not been rectified by the management team at the time of this inspection and there were still discrepancies in people’s care plans and risk assessments. Although risks were not overlooked or ignored, lessons had not always been learned or fully embedded into consistent practice over time, from complaints previously received in 2025 and 2026 regarding a lack of staffing, no stimulation or meaningful activities for people, missing clothing and poor oral care.

The local authority who had been regularly monitoring and supporting the home were also concerned about the providers’ ability to learn from past issues. A staff member told us, “There are very few debriefs following an incident.” A relative said, “[Person] recently cracked [their] hip and no-one here [staff] can explain to us how or when it happened.”

Formal systems to electronically record incidents and accidents which included actions taken, who had been informed, and any lessons learned, were in place.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Initial assessments were completed when people first moved into the home, which provided staff with an overview of people’s care needs and how they needed to be met. A staff member told us, “When residents are moved into the service it is communicated by managers who are the ones who assess residents for which care unit they require. They inform staff of an outline of health and care needs but not wants and wishes.” A second staff member said, “Assessments and plans sometimes come with the resident, but if they come from hospital, then not much information comes.”

The manager commented, “When we receive a referral, we initially respond with a phone call. If the referral is via the local authority or from the continuing health care team, they will send us an initial needs portrayal for the person. The family and the prospective resident are invited to come and have a look around the home. We then arrange to visit the person to carry out a comprehensive preadmission assessment. We involve the family, especially if the person has a poor memory, to find out about the person’s life history and current needs.”

Records showed information about people was available and shared with health care services when needed. For example, key information about people’s health conditions was shared with relevant other health care professionals to ensure safe transitions, when people attended hospital.

People’s care plans showed they received support from a wide range of other health professionals including dieticians and doctors where needed. The provider used a post-admission 72 hours audit following a new person moving into the home; this considered areas such as pre-admission information, risk assessments, baseline checks, mobility, nutrition and personal care information.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Although the provider had policies in place to guide staff in maintaining people’s safety, these were not consistently implemented in practice. For example, an altercation had taken place between 2 people which should have been dealt with under the providers safeguarding procedures but was not. For another person, there was no mental capacity assessment in place for the use of a chair sensor. A clinical audit document was completed each week for each house and was used to track any necessary safeguarding actions; however, the audits had not identified these issues.

From looking at wound related monitoring records we found there were other occasions when a safeguarding referral should have been made to the local authority, but this had not been done. This meant opportunities to prevent avoidable harm reoccurring were occasionally missed.

Some relatives said they were not fully informed about incidents or changes in risk levels. This limited the provider’s ability to ensure decisions about safety were person-centred, respectful of people’s rights, and properly explained. A relative told us, “I spoke to the last manager about the falls [person] has had; [they] did nothing, so I don’t think the home was well managed. I don’t know the new manager, or if she will do anything. When [person] fell and fractured [their] hip, no one knew what had happened and no one has tried to find out.”

A safeguarding policy was in place and shared with staff. However, the manager had not updated this policy with the home name, and the local authority contact details, as instructed in the policy.

Most staff had a good understanding of safeguarding. One staff member told us, “Safeguarding concerns could be when residents or people experience harm or when they are neglected. It could be an incident or an accident which has been unwitnessed. We need to ensure we raise this to our management. We report them on the electronic care system as well. I would not have any concerns about raising safeguarding concerns. I have no concerns about the safety of the residents. I think all the people who live here are safe.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Although systems were in place to record the ability of people to consent to care and treatment, this was not consistently acted upon. For example, one person lacked capacity and was diabetic; records identified this person ate high sugar food items such as biscuits and donuts, however, the associated risk assessment and mental capacity assessment was not in place showing how this was being monitored, or how this was in the person’s best interests.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not consistently provide care which met people’s needs in a way that was safe, supportive, and person‑centred. Staff did not consistently follow care plan guidance intended to keep people safe. People were not always encouraged or enabled to make choices, maintain independence, or engage in activities important to them; this limited their autonomy and reduced opportunities to live fulfilled, meaningful lives.

Auditing and monitoring systems had failed to identify or rectify gaps in the delivery of care which reflected people’s individual needs. As a result, the provider did not demonstrate the behaviours, culture, or practices expected to keep people safe and support them to achieve good outcomes.

Some people were not always wearing appropriate footwear, as identified in their care plans, which presented a falls risk and Zimmer frames were not always being used for people to mobilise safely. We observed several occasions when relatives had to assist people to mobilise. Mattress checks were not always documented for some people.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There was no communal bath on one side of Martin house, and the other bath was not in working order; people were receiving a body wash instead. Relatives told us people were not regularly receiving a shower or bath. Staff told us the bathroom had not been in use since December 2025; they also told us the shower room had not been designed well, so the water did not drain away easily, and their feet got wet resulting in wet footwear for the rest of their shift. This presented an infection control risk.

Radiators were not always fitted with safety covers to prevent the risk of burns and scalds. Chairs were not cleared away after breakfast on Martin house which presented a trip hazard for some people when walking. Mattress checks were not always documented in the electronic care planning system for some people.

The provider had environmental checks folders for all the units. For Martin house, there were several checks for January 2026 which had not been ticked off as being completed including communal area inspections, back of house inspections, minibus checks, safety systems checks and heating and cooling checks. Furthermore, checks from December 2025, indicated improvements were required such as wardrobe repairs and painting of decor, however, the audit documents did not indicate these tasks had been completed despite them being identified over 2 months previously.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There were insufficient numbers of staff deployed to meet people’s needs. We observed 3 examples on Martin house where there were not always enough staff available to support people safely. One person repeatedly got up from their chair which caused an alarm to activate; however, no staff arrived to support this person due to being elsewhere in the unit; the person’s care plan stated they required the assistance of 1 staff to mobilise.

Another person mobilised on several occasions without staff support as there were no staff in the lounge area. The person’s care plan stated they required the assistance of 1 staff to mobilise. We observed many occasions where relatives had to assist people to walk, due to a lack of staffing. A staff member told us, “The staffing levels at the home are not always great; there are good and bad days, especially in cases of staff ringing in sick. Dependency on the units also puts a lot of pressure on staff and not all staff are swift with their job; some require extra time to get things done which can slow down the workload.”

On one occasion, we observed an agency staff member on Albion house leaning against a wall in the lounge area for 20 minutes without engaging with any people or staff. Three other staff members were busy giving people their medicines and providing breakfast to people in the dining room and in their own rooms. We informed the operations director about this who told us a business case had been submitted for a unit lead on each unit and an activity coordinator on each unit. The operations director also said managers needed to be present on the units and the senior staff needed to be empowered to speak to staff and monitor them, but they did not currently have the confidence.

People and relatives consistently told us they felt there were not enough staff on duty and staff felt the same. Our review of some historical complaints also showed there had been numerous concerns regarding staffing levels. A relative told us, “There are times when I think they are short staffed due to staff absences; I feel sorry for the extra pressure it puts on the staff.” A second relative said, “Staff levels are not high enough; they could do with at least 1 more member of staff and someone to do some more activities with them.” A third relative commented, “The staff are lovely with [person], but there are not a lot of staff around. Yesterday it took me 10 minutes to get somebody to get [person] out of [their] chair.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The floor on Martin house was dirty and not cleaned between breakfast and lunch on one day; lots of food was on the floor which people were walking in, and drinks spillages were not cleared from people’s tables. The linen cupboard on Martin house was open and had towels and sheets located on the floor which looked dirty. There was an underlying mal odour on some units.

There were personal protective equipment (PPE) stations located throughout the home, and staff were wearing PPE when completing personal care and when serving food. However, on Martin house we saw a staff member was wearing a PPE mask, but they were not wearing it correctly; the same member of staff was wearing a PPE apron whilst a fellow staff member did not have PPE on but was supporting people with lunch.

A staff member told us there were not always housekeepers on the units due to sickness and therefore staff had to complete that role; in addition, care staff had to do the washing up at dinner time as the housekeepers left at 4pm. We observed a section of flooring which was frequently damp with saliva, and despite routine cleaning, it appeared the level of disinfection was not sufficient to fully mitigate the risk.

People, staff and relatives had concerns regarding the cleanliness of the home. One staff member told us they had concerns about the amount of work the laundry staff had to do. They told us the laundry team used to have 4 people on shift, but now there was only 2 staff. They said, “We are dealing with hundreds of bags of washing per day which is impacting on staff morale. One of the staff has gone off sick and another one is due to retire soon. I feel staff are not listened-to by management. This is the worst I have known the home to be.”

There was an up-to-date infection prevention and control policy in place and staff had been trained in infection control. The operations director sent us a new ‘critical daily walk round’ document which they said the manager would complete moving forward; this document included checks on the cleanliness of the environment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were stored securely and areas which were used to store medicines had the temperature monitored. Staff had access to medicines training which included management of thickeners and diabetes. We saw evidence some staff had not completed all the training required. Staff had completed their competency assessments for managing medicines.

Protocols for staff to follow for medicines prescribed to be given when required (PRN) contained person centred information. People’s prescribed patches did not always have the location it was applied recorded on the electronic medication administration record (EMAR). This meant we could not be assured application sites were rotated as required by the manufacturer’s instructions.

For 3 people who had their medicines crushed prior to administration there was not always clear instructions from an appropriate healthcare professional on the EMAR available for staff to follow to ensure these medicines were administered safely. For one person, staff were unable to provide a record of a best interest decision being completed to ensure the appropriate people were involved in decision making. After the inspection, the manager advised us all people receiving their medicines covertly (hidden in food or drink), were having their medicines reviewed by their GP.

Although we did not see any gaps in recording of medicines on the EMAR, we found the balance of stock did not reconcile with the expected stock on the EMAR for 3 people, and 1 person received their antibiotic for more days than it was prescribed. This meant we could not be assured medicines were always administered as prescribed.

Powder used to thicken drinks for people at risk of choking and aspiration was stored securely and usage was documented on the care notes system. For 2 people, there were instances where this was not recorded accurately.

Care plans contained information for staff on managing people’s long-term conditions and how they took their medicines. For 3 people, we found incorrect information in care plans. However, we were told this was rectified by staff on the day of the inspection, once notified.

Medicines needing to be administered at a specific time or needing a timed gap between doses were recorded as being given as prescribed. People were supported to look after and administer their own medicine if they wished. Staff had completed risk assessments to ensure this was appropriate.

Staff completed audits of medicines and action plans were created if issues were found. Incidents related to medicines were reported by staff and investigations and actions took place.