Millfield House

We conducted the inspection to follow up on actions taken by the provider regarding concerns identified at the previous inspection and in response to information of concern regarding the culture at service, the cleanliness and safety of the building and people’s welfare. Although we were assured in most areas for which concerns had been raised, other concerns were identified that people were not always receiving care that was safe or effective.

The service was last rated “Requires Improvement” in January 2023 with breaches of the legal regulations regarding safe care and treatment and good governance. The provider had failed to meet these breaches of regulation and we identified a further breach of regulation regarding staffing. The rating of Millfield House remains “Requires Improvement”.

Although staff were caring and compassionate, they were not always sufficiently knowledgeable about people’s needs or how to support them safely. There were not always staff available who had appropriate training in tasks such as giving medication or leading a fire evacuation.

It was not always clear that people were receiving care in line with their needs due to care records being insufficiently detailed. We therefore could not be assured that care being given was always safe. Some risks were not always safely managed which put people at a greater risk of harm.

Governance processes were not always robust and had not ensured concerns were always proactively identified and responded to in order to maximise people’s safety.

However, people described a significant positive impact that the service and individual members of staff had on their quality of life. They were able to live with independence and choice, which empowered them to build positive relationships with their peers and explore and grow individual interests and passions. People were treated with kindness and compassion by staff they had close bonds with, although there was a large turnover of staff which impacted on continuity of care.

The service had formed strong collaborative relationships with partner organisations and worked together with them to provide joined up care in response to people’s health and care needs. This included supporting people to improve their independence and wellbeing, which allowed them to have greater control over their own lives.

People felt at home at Millfield House and could use the space as their own, including socialising with peers, visiting the community or spending time in their rooms. The property was largely well maintained with appropriate checks on the building taking place regularly. However, the building was not always suited or accessible to people with a physical disability. We also identified concerns about evacuation procedures in case of a fire, as staff were not sufficiently trained or knowledgeable in how to manage this.

A new manager had joined the service in October 2025 and were waiting to submit their application to become registered manager. All people we spoke to had noted the impact they had made to the service and were confident that they had the skills and vision to achieve longer term improvements.

We assessed the service against ‘Right support, right care, right culture’ (RSRCRC) guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities which most people take for granted. We found the service was acting in line with the principles of this guidance.

The provider was responsive to concerns raised during the inspection including taking immediate action where areas of risk were identified. We have asked for an action plan to be submitted setting out how the identified breaches in regulation will be met.