Archived: Melrose House

Updated 4 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by one inspector.

Service and service type

Melrose House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Melrose House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the Local Authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with 3 people who used the service and 1 person’s relative about their experience of the care provided. We spoke with 2 members of staff and the registered manager. We also spoke with the provider and external consultant. We reviewed 3 people’s care plan and risk management strategies. We also looked at the provider’s quality assurance systems, the provider’s arrangements for managing medicines and staff training and supervision records.

Updated 4 July 2023

About the service

Melrose House is a residential care home providing the regulated activity of accommodation and personal care to up to 34 people. The service provides support to older people, including those who are living with dementia. At the time of our inspection there were 12 people using the service.

People’s experience of using this service and what we found

Minor improvements were still required to the service’s risk management strategies and medicine records to ensure these were safe. Some further improvements were still required to the care home environment. Although there was no impact for people using the service, not all staff had attained up-to-date training or received regular formal supervision.

Suitable arrangements were in place to keep people safe. Policies and procedures were followed by staff to safeguard people and staff understood these measures. Risks to people were identified and managed to prevent people from receiving unsafe care and support. The service was appropriately staffed to meet people’s needs. People were protected by the providers arrangements for the prevention and control of infection. Arrangements were in place for learning and making improvements when things go wrong.

People's nutritional and hydration needs were met, and they received appropriate healthcare support as and when needed from a variety of professional healthcare services. The service worked together with other organisations to ensure people received coordinated care and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 11 January 2023).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 22 to 28 November 2022. Breaches of legal requirements were found relating to risk management, preventing, and controlling infection, the premises and the provider’s governance and quality assurance arrangements.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained unchanged. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Melrose House on our website at www.cqc.org.uk.

We also looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.