Millbrow 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question requires improvement. At this inspection this key question has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Nearly all of the staff told us they liked working for the provider. Comments from staff included “The manager is lovely; they have really made so many positive changes here.” Another staff member said “I really do think the home is ran well. The manager is great.” Another staff member said “Yes, [managers name] is really good. They have stepped into their role and do a great job.” We did receive some feedback around the registered manager being mostly office based which could mean they did not always know what was going on in the home. We fed this back during our feedback.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager was honest and open with regards to some of our feedback. They admitted they did not always feel records were a true reflection of the work the staff did. However, they were able to demonstrate additional steps they were taking in response to this.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. All of the staff except 1, felt they could raise concerns with the registered manager and they would be acted upon promptly.

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. Staff from different backgrounds told us they felt well supported by other staff and the managers to feel included and part of the team.

The provider now had clear responsibilities, roles, systems of accountability and good governance. They now used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. For example, all of the issues we raised during our site visit had already been identified by an audit recently completed by the registered manager. The redecoration process was due to start imminently. The registered manager understood duty of candour and had notified CQC of all reportable incidents.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider had good relationships with the district nurses and general practitioners, and other community teams. This meant the registered manager could request appointments, care or medical reviews and these were allocated in a timely manner.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. For example, the providers responsiveness from this inspection showed a clear keenness to improve on some areas and ensure the home was running as well as possible for the people who lived there.