Mill View 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 requires improvement. At this assessment the rating has remained 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 provider was in breach of the legal regulation relating to good governance.

This service scored 50 (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 had not made the necessary improvements in response to the concerns identified at the last inspection, and we found similar issues relating to unsafe care and poor outcomes for people. The new manager had only been in post for approximately 3 weeks prior to our inspection and had not had time to make any meaningful improvements, despite there being constant senior management support at the home, prior to them taking up post.

Since our last inspection, work had taken place regarding the culture within the home. However, there was a distinct lack of vision for the service and what it should look like. The provider needed to do more in developing a clear vision and plan, communicating this to staff and people, and putting this into practice across the whole home. This was reinforced from our discussions with staff who were unable to clearly explain the vision and values. One staff member told us, “Staff communicate with each other and work together as a team; as for management it’s their way, or no way.”

Several staff told us about insufficient staffing levels. One staff member said, “At present the staff are burnt out, including the nurses who never get a break during their 12-hour shift. Definitely more staff are needed to assist residents with personal care and mealtimes so that they receive the care they so rightly deserve.” People and relatives were unsure about management arrangements. One relative told us, “I don’t think the new manager has made her mark yet, especially with the staff. I’m not really sure who is in charge on the unit.”

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 did not always do so with integrity, openness and honesty.

There was no evidence the provider had undertaken an analysis to determine why previous managers of the home had not stayed in post and had not registered with CQC. We found repeated issues at this inspection which were similar to those previously identified; these ongoing issues demonstrated previous concerns had not been addressed and risks to people remained. Insufficient progress had been made to support effective governance arrangements. A staff member commented, “Nurses and senior carers do a great job, but more and more work is put onto them, which is stressful. Management are a waste of time; not approachable.”

Leaders were not always aware of the issues we found during this inspection and were not always visible within the home. Not all people and relatives knew the manager. Six relatives told us they had not been given any information about the home. A person told us, “I don’t know who the manager is. I am not sure who is in charge in this room.” A relative said, “I have not spoken to the new manager, so I can’t comment what [they are] like, I haven’t seen [them] around the unit when I have visited.” A staff member told us, “On some shifts, I have been asked to be a cleaner, activities coordinator and a carer on one shift. It’s just ridiculous the amount we are being asked to do.” The manager commented, “I have only been at the service for 3 weeks. It is hard to meet all 120 staff all at once and I am making my way around this.”

People did not always feel they could speak up and that their voice would be heard.

People and relatives told us concerns raised were not always acted upon. For example, one relative told us, “I have raised a concern about [person’s] bedroom, it doesn’t have a toilet, so [person] has a commode, but it never has a bucket in, so [person] can’t use it. I have mentioned it, but nothing has happened. I have also asked if [person] could have a bath, but last December they said the bath was broken and it is still out of use.” A second relative said, “I don’t know who the new manager is, [they haven’t] introduced [themselves] yet. I can’t tell you who is in charge on this unit either.” A third relative stated, “The last manager was not helpful; I don’t know the new manager at all.”

Staff felt they would be listened to. One staff member said, “We have done e-learning on speaking up and there are posters all over the home telling you about whistleblowing.” A second staff member told us, “I am aware of the freedom to speak up, and this means I am free to escalate any concerns to the management.”

We looked at a sample of other complaints received and found these had been investigated appropriately. However, learning from previous complaints had not been fully embedded into practice.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff were representative of the population of people being supported and had access to equality training to help them understand about protected characteristics, bullying and harassment. A staff member told us, “A lot of staff have flexi contracts which management keep saying need to be looked at. In a nutshell if staff are happy then you have a happy home, happy families, happy residents and business. Us as staff basically run the home; if it wasn’t for us they [the provider] wouldn’t have a business to run.”

Consistent leadership was required to ensure a sustained positive culture within the home. Staff did not always work well together. A staff member told us, “Senior staff can sometimes be very rude; they can just sit in their office doing paperwork. Other seniors are different and get involved and actually do some care work. It really is dependent on who you get on shift.” The operations director told us, “Managers need to be on the units and not in the office all the time, and also the seniors need to be empowered to speak to staff and monitor them, but they do not currently have the confidence.”

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.

There had been no registered manager in post for over 2 years; the last registered manager deregistered on 14 February 2024. Under the Care Quality Commission (Registration) Regulations 2009, any organisation carrying on regulated activities must have a registered manager for every regulated activity it carries on, unless it is a health service body. The provider was unable to clearly identify why previous managers had not stayed in the role long enough to register with CQC. A relative told us, “I am not sure how well managed the home is. When I spoke to the old manager about concerns, nothing ever happened. I haven’t seen the new manager to raise any concerns yet.”

Inconsistencies in the leadership team and senior staff roles over 2 years had contributed to a lack of stability within the home, and the ability to effectively govern the service, despite several different senior leaders supporting the home since February 2024. A staff member told us, “There needs to be a clinical lead in post as there used to be, but this was taken away; staff have told managers, but managers are not listening.”

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider was working collaboratively with the local authority and other system partners to help drive improvements within the home. Regular partnership meetings had taken place, where progress against planned actions had been reviewed. We spoke with representatives from the local authority who told us they were constantly engaged with the provider; however, they said the necessary improvements had not been made or sustained, and the improvement plan which was monitored at monthly meetings with senior managers was not of good quality.

At the time of the inspection, local authority monitoring and support was ongoing, and any new referrals into the home from the local authority had been temporarily suspended. Despite this external support, there was a continued failure to achieve and sustain the required improvements. Progress was limited, and actions were not embedded into day‑to‑day practice. These gaps indicated partnership working, although present, was not sufficiently effective in driving meaningful or lasting change within the service.

An organisational safeguarding enquiry was ongoing at the time of this inspection, and this included several historical issues which had not been adequately addressed and escalated by the provider in a timely way.

There was limited evidence to identify how people were supported to integrate within their wider local community.

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 provider’s auditing systems were not always robust. The provider had a range of checks and audits to monitor the quality and safety of the service and to help drive improvements. However, although auditing systems had identified some of the issues we found during this inspection, they had not resolved them. These issues were similar to issues found at our last inspection.

Systems to review and learn from care records and documentation were not always effective. The provider had not resolved the issues regarding staff not consistently keeping accurate, contemporaneous records of people’s care and support, and as a result the providers’ ability to learn from staff practice, monitor quality or implement improvements based on reliable information, was limited in success.