Mill House

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

The service was not well-led and remains inadequate. Not enough improvements had been made. We identified 1 breach of the legal regulations. The systems in place to make improvements and identify concerns were not effective. The home was not well managed. There was a lack of understanding and accountability. There was limited evidence of learning, and we continued to find repeated concerns identified at previous inspections.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although staff felt supported and felt the manager was approachable, they described a lack of confidence with how the home was managed. Staff also felt there had been a lack of input from the provider. The manager was unable to demonstrate to us they understood their role. They did not have an understanding in key areas such as safeguarding. For example, they did not understand they had needed to report a serious incident that had occurred prior to our inspection, when we discussed this with them, they were unaware this would be a safeguarding concern. This placed people at risk of harm. The provider was unavailable during our inspection, however, did speak with us briefly on the telephone at the end of the inspection, where we offered him feedback. He was not responsive to this.

The home was disorganised and there was a lack of leadership. There was no registered manager in place. There was no evidence of clear and effective roles, accountability and oversight within the management team. This meant we had a lack of assurance in how the service continued to be managed. A consultant was working within the service however was discontinued after our inspection. After our last inspection we shared our concerns around the management of the home. However we found effective action had not been taken and the same concerns were present at this inspection. The provider had failed to take action to ensure a suitably qualified skilled and competent person had oversight of the home. We had not been notified of all notifiable events that occurred within the service. The provider has a legal responsibility to do this.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff felt some new ideas had been introduced since the last inspection. However, they raised concerns as they felt the management team didn’t always follow through or involve them in the review of changes to the service. They used staffing levels as an example as staffing numbers had initially been increased following our last inspection but had reduced again during the afternoons. The manager told us the number of audits being completed at the service had increased and they spoke positively about the consultant who had been working at the service. However, they were unable to explain how the audits were improving safety and care.

The audits and checks that had been introduced were not effective. For example, the maintenance audit had not identified concerns with the environment and medicines audits had not identified ‘as required’ protocols were not always in place. Safeguarding audits had not identified concerns were not being identified, investigated or reported. Systems and processes in place had also failed to identify mental capacity assessments and best interest decisions were not in place for people when needed. This placed people at a continued risk of harm.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us things were not always dealt with promptly in the home which caused potential risk to escalate. A staff member told us, “I don't feel risk is managed upstairs, you don't wait for it to happen.”

After our last inspection we imposed a condition on the providers registration which included sending us monthly action plans ensuring a suitably qualified skilled and competent person had oversight of the concerns we identified during our last inspection. We found the systems in place to ensure improvements were being made were not effective. Information that had been sent to us in these action plans was not always accurate. For example, we were told concerns with window restrictors had been addressed when this assessment identified they had not. There was a lack of effective systems to drive learning and improvement at the home. This was evidenced by 4 continued breaches from the previous inspection and 1 new breach.