Milverton Road

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 this assessment, we looked at 3 quality statements. For the quality statements not inspected, we used the scores awarded at the last inspection to calculate the key questions rating. Based on the findings of this assessment the rating for this key question has changed from good to requires improvement. This was because we found concerns with the effectiveness of how the service operated their governance systems and responded to issues found. The service experienced a drop in staffing levels. This lack of stable staffing has negatively impacted on the services culture and ability to operate their monitoring systems effectively. These failures had placed people at risk of harm under 1 breach of Regulations. Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The service did not always have clear systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this in a timely manner with others when appropriate. Leaders expressed they were working closely with partner agencies to address concerns and drive improvements at the service, and to the people they support. Leadership meetings are held twice a year within the organisation to discuss updates on new systems, initiatives and lessons learnt.

The provider had governance and monitoring systems in place, however the service did not always effectively implement their established governance systems to identify and drive improvements at the service. The service completed 3 monthly audits; their most recent audit scored 89%. Whilst we saw some evidence of actions taken to prevent reoccurrence of incidents and lessons learnt being recorded in team meeting minutes and supervision records. We did not see actions taken as a result of some of the shortcomings identified. For example, the service did not always identify gaps in people’s care records and MARs, and audits of stock medication were not effective, raising concerns about the efficacy of their governance and monitoring systems, and how they were being applied. This is a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. Local Authority reported delays in the service seeking medical advice when people’s needs deteriorated, in addition to delays in the reporting of safeguarding concerns. Local Authority also raised concerns with actions taken as a result of shortcomings identified in internal audits. We also found some delays in the reporting of statutory notifications to us. They did not always share information and learning with partners or collaborate for improvement.

Though management acknowledged areas requiring improvement, they were unable to clearly articulate actions implemented to mitigate the recurrence of incidents. For example, in the event of medication errors. Management was not able to outline strategies to enhance effectiveness of medication audits.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice. The service failed to ensure sufficient action had been taken to address shortcomings and improve the quality of the service provided to people. Despite internal audit identifying concerns in August 2024 and a subsequent external audit by the Local Authority in September 2024 also highlighting similar issues, no improvements were implemented to address these matters as we found similar concerns on the assessment on 27 November 2024.