Mill Hayes

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

We assessed a limited number of quality statements in the well led key question. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. At this assessment the rating has changed to requires improvement. This meant the services management and leadership was inconsistent. We found 1 breach of the legal regulation in relation to good governance. Quality monitoring and record keeping did not always support the delivery of high-quality, person-centred care. Staff told us the culture of the service focused on people’s safety. However, some staff told us further improvements were needed when promoting people’s independence skills and addressing conflicts between staff. Quality auditing processes were taking place. However, these audits had not always identified the discrepancies found during this assessment. Monitoring of people’s health needed further improvement to ensure records were kept up to date. Further improvement was needed to ensure risks to people were assessed, monitored and concerns escalated in accordance with people’s assessed need. The manager was new to the service and in the process of registering with us. The manager responded to all our feedback and introduced new systems and processes to audit the care and support provided. We will review the success of these new systems in the next assessment. Staff told us the new manager was approachable and supportive.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from staff over the culture of the organisation. All staff we spoke to told us culture focused on keeping people safe. However, 1 staff member told us sometimes staff conflicted with each other, and another staff member told us more work was needed to promote new activities and independence skills.

The provider shared their statement of purpose which aimed to promote an inclusive and empowering environment. Key worker sessions took place to review people's care and discuss their goals. However, care plans and daily records did not always reflect how people were being empowered to engage in daily activities or develop independence skills. The provider shared their action plan which included steps they were taking to improve governance systems in order to monitor care records more efficiently.

The manager was new to the service. Staff told us they believed in the new managers ability to lead. One staff member said, “The manager is approachable, leads by example and is very supportive.” Another staff member told us, “The manager is approachable. I have never raised any concerns, but I could do, I know they would be acted on.”

The manager raised notifications in line with regulatory responsibility and understood their duty of candour. Apologies were made when things went wrong, and complaints were acted upon. However, members of the management team did not always lead by example when adhering to their infection prevention control (IPC) policy. A recent IPC audit highlighted staff were not wearing the correct attire when working with people, this was due to the use of nail polish / wearing false nails. This was in breach of the provider’s policy and staff were spoken to. On both site visits we noted members of the management team were also not adhering to their own policy and not leading by example. We passed this on to the regional manager for review.

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 told us they understood their responsibilities and duties. However, 1 staff member told us they wanted further development opportunities and responsibilities. We discussed daily recordings with the management team. The manager agreed more work was needed to record how staff interacted and promoted people’s independence. The manager responded to our feedback by arranging a development activity for staff to improve recording skills and they shared development opportunities for staff.

Quality audits were taking place for safe handling of medicines, health and safety and care documentation. However, these had not identified the discrepancies found during this assessment and some audits lacked specific detail regarding which person’s care documentation had been audited. Care plans were not kept updated with people’s changing needs, care monitoring was not audited robustly and room temperatures for medicines had gaps in the recording. The manager responded to our feedback and introduced new monitoring systems. We will review the success of these systems during the next assessment.

The service worked in partnership with people and relatives. Relatives told us they felt included in the service and received regular updates regarding people’s health and wellbeing.

We received mixed feedback from staff regarding partnership working. One staff member told us they were able to make suggestions and share ideas during team meetings. They said, “There are regular team meetings. We [staff] can make suggestions in team meetings. The manager listens.” However, another staff member told us, “Team meetings feel more like managers talking at staff. We are not asked to make suggestions.” We observed staff working in partnership with other professionals such as health professionals to promote people’s wellbeing.

Visiting professionals told us the provider regularly sought feedback from people relatives and staff. Although they raised concerns over the quality monitoring systems in place. Visiting professionals told us they had concerns over the amount of meaningful activities offered to people to promote their wellbeing. The manager responded to this feedback by sharing a wide range of activities people had recently enjoyed and shared plans for future activities.

Records reflected how the provider worked in partnership with visiting professionals. However, care plans needed updating with the most recent recommendations from visiting professionals.

A recent visit from visiting professionals highlighted improvements were needed to the care and support people received. The manager discussed the visit with us and shared actions they were disputing, and actions they had taken to address areas of improvement. However, some of the concerns highlighted from the professional's visit continued to be found during this assessment, further improvements were identified regarding care monitoring, recording and governance processes.

The provider learned lessons from incidents of distressed behaviour. Trends and patterns were analysed, and lessons learnt were shared appropriately. However, actions identified from visiting professionals were ongoing and improvements were identified to safe storage of medicines, risk assessments, mental capacity assessments and record keeping. The provider responded to all areas of our feedback and introduced new governance systems. We will review the success of these new systems in the next assessment.