Archived: Melrose House

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.

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 13 people using the service.

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

Quality assurance arrangements were in place to assess and monitor the quality of the service provided. Whilst there was evidence available to demonstrate improvements had been made since our last inspection to the service in April 2022, improvements were still required to ensure risks and regulatory requirements were understood, managed and actioned. This related to the ongoing improvements required relating to the premises and the service’s fire risk arrangements.

Not all environmental risks for people using the service were safe, ensuring their safety, comfort and wellbeing. This referred to the fire safety and heating arrangements at Melrose House. Although the premises were clean and odour free, there was inadequate domestic cover at Melrose House to help control the spread of infection.

People told us they were safe. Suitable arrangements were in place to protect people from abuse and avoidable harm. Staff understood how to raise concerns and knew what to do to safeguard people. Enough numbers of staff were available to support people living at Melrose House and to meet their needs. Medication practices were safe and ensured people received their prescribed medication.

Staff received mandatory training and newly appointed staff received an induction. Staff felt valued and supported by the registered manager and received formal supervision. The dining experience was positive and people received enough food and drink to meet their needs. People were supported to access healthcare services and receive ongoing healthcare 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

The last rating for this service was requires improvement (published 13 June 2022).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We 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.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to those risks associated with the environment at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Melrose House is a residential care home providing accommodation and personal care to up to 34 people. The service provides support to older people and people living with dementia in one adapted building. At the time of our inspection there were 18 people using the service.

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

Although risks to people’s safety and wellbeing were assessed and recorded, not all risk strategies were being followed by staff to ensure people’s safety. The service had experienced recent challenges relating to staffing levels. Whilst steps had been taken to address this, the deployment of staff was not always suitable and communal lounge areas were left unsupported.

Where issues were raised relating to staff’s conduct or their performance, no information was recorded to demonstrate how this was being monitored to ensure positive outcomes and lessons learned. The dining experience was not positive for all people using the service and improvements were required. Not all people using the service had had their oral healthcare needs assessed and a care plan compiled. Not all people were supported to maintain good oral healthcare.

Not all people were supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Quality assurance arrangements were in place to monitor the quality of the service provided. Whilst there was evidence available to demonstrate some improvements had been made since our last inspection to the service in June 2021, these arrangements required improvement as they had not identified the issues found during our inspection.

Staff knew how to keep people safe from harm and people told us they were safe. Medication practices ensured people received their medicines as they should. Suitable arrangements were in place to recruit staff to ensure people would be supported safely. People were protected by the registered provider’s infection control practices and procedures. People received training and an induction.

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 August 2021].

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.

This is the second consecutive time the service has been rated Requires Improvement.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

During this inspection we carried out a separate thematic probe, which asked questions of the provider, people and their relatives, about the quality of oral health care support and access to dentists, for people living in the care home. This was to follow up on the findings and recommendations from our national report on oral healthcare in care homes that was published in 2019 called ‘Smiling Matters’. We will publish a follow up report to the 2019 'Smiling Matters' report, with up to date findings and recommendations about oral health, in due course.

We 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Melrose House is a residential care home providing accommodation and personal care to people aged 65 and over. At the time of the inspection there were 21 people living at the service. The service can support up to 34 people. The care home accommodates people in one adapted building.

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

Quality assurance and governance arrangements at the service were not as reliable or effective as they should be in identifying shortfalls in the service. Improvements were required to the service’s recruitment practices and procedures. Not all staff had received training or up to date training to ensure they were skilled and competent. These areas had not been picked up by the service’s quality assurance arrangements.

Risks were identified and recorded. People told us they were safe and suitable arrangements were in place to protect people from abuse. People were protected by the service's prevention and control of infection practices and from the risk of transmission of COVID-19 and other infectious diseases. The environment was clean and odour free.

Staff felt valued and supported by the management team and received regular supervision. The dining experience for people was good and people received enough food and drink of their choice to meet their needs. People were supported to access healthcare services and receive ongoing healthcare support. The service worked with other organisations to enable people to receive effective 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

The last rating for this service was Good (published March 2018).

Why we inspected

This was a planned inspection based on the previous rating.

We 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.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe, Effective and Well-Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

• The registered manager had followed the government's guidance on whole home testing for people and staff until the outbreak of COVID-19 at the service in January 2021.

• People's well-being was being supported by window visits and use of the Facebook portal device. A visitor's pod had been newly built within the service’s grounds and would be fully operational by 8 March 2021. This will enable people using the service to have face-to-face contact with their relatives.

• Arrangements were in place for relatives to visit family members who were judged to be at the end of their life. Suitable measures were in place such as temperature checks and Personal Protective Equipment [PPE] to keep infection risks to a minimum.

• Staff employed at the service had received training on infection prevention and the correct use of PPE. There was clear guidance and signage located within the service to help promote staff to safely work whilst minimising the risk of spreading infection including effective hand washing practices.

• Appropriate infection prevention control practices were observed, such as the wearing of masks, gloves, aprons and also included good hygiene practices.

• The environment was visibly clean. Cleaning schedules evidenced the frequency of cleaning undertaken, including deep cleaning of the service.

• People living in the service were encouraged and supported to maintain social distancing in communal areas, such as the lounge and dining room.

• Suitable arrangements were put in place during the outbreak of COVID-19 to separate the environment for people who had tested positive and those who were not, to minimise the risk of transmission.

Melrose House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 34 older people and people living with dementia.

Melrose House is a large detached building situated in a quiet residential area in Southend on Sea and close to all facilities and amenities. The premises is set out on three floors with each person using the service having their own individual bedroom and adequate communal facilities are available for people to make use of within the ground floor.

At the last inspection on the 19 and 20 September 2017, the service was rated ‘Requires Improvement ’. A breach of regulatory requirements was evident for Regulation 13 [Safeguarding service users from abuse and improper treatment], Regulation 17 [Good governance] and Regulation 18 [Staffing]. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of ‘Safe’, ‘Effective’, ‘Caring’, ‘Responsive’ and ‘Well-Led’ to at least good. The home improvement plan was received on 24 November 2017. At this inspection, we found the service had made significant improvements and was now rated ‘Good’. However, ‘Well-Led’ was rated ‘Requires Improvement’. This is because the location has a condition of registration that it must have a registered manager, but it does not have one. We held an internal management review meeting on 1 February 2018 and agreed that the service no longer needed to remain in ‘Special Measures’ and the condition imposed on the registered provider’s registration in 2016 removed.

Our key findings across all the areas we inspected were as follows:

Suitable arrangements were now in place to assess and monitor the quality of the service provided. There was a positive culture within the service that was person-centred, open and inclusive. The registered provider and manager were able to demonstrate a better understanding and awareness of the importance of having suitable quality assurance processes in place. This was a significant improvement and this had resulted in better outcomes for people using the service. Feedback from people, those acting on their behalf and staff were positive. This referred specifically to there now being confidence that the registered provider and management team were doing their utmost to make the required improvements.

Suitable arrangements were now in place to take action when abuse had been alleged or suspected. People were protected from abuse and avoidable harm and people living at the service confirmed they were kept safe and had no concerns about their safety and wellbeing. Policies and procedures were being followed by staff to safeguard people and staff now understood the importance of these measures. We observed that staff followed safe procedures when giving people their medicines. Medicines were stored safely and records showed that minor improvements were required to ensure people received their medicines as prescribed.

Risks to people were clearly identified and managed to prevent people from receiving unsafe care and support. People were protected by the provider’s arrangements for the prevention and control of infection. Arrangements were in place for learning and making improvements when things go wrong.

People were treated with care, kindness, dignity and respect. People received a good level of care and support that met their needs and preferences. Support plans were in place to reflect how people would like to receive their care and support, and covered all aspects of a person's individual circumstances. Staff had a good knowledge and understanding of people’s specific care and support needs and how they wished to be cared for and supported, including end of life care.

Social activities were available for people to enjoy and experience.

Comments about staffing levels from people using the service and staff were positive. The deployment of staff across the service was observed to be appropriate and there were sufficient staff available to meet people’s needs to an appropriate standard at all times.

Safe recruitment practices were in place and being followed. Induction arrangements for staff newly appointed to the service had been reviewed to ensure they were able to carry out their role and responsibilities effectively. Staff now had the right competencies and skills to meet people’s needs and had received updated training. Suitable arrangements were now in place for staff to receive formal supervision.

People’s nutritional and hydration needs were met and they were provided with drinks and snacks throughout the day. People received appropriate healthcare support as and when needed from a variety of professional services. The service worked together with other organisations to ensure people received coordinated care and support.

Staff understood and had a good knowledge of the Deprivation of Liberty Safeguards [DoLS] and the key requirements of the Mental Capacity Act [2005]. Suitable arrangements had been made to ensure that people’s rights and liberties were not restricted. Staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were routinely asked to give their consent to their care, treatment and support and people’s capacity to make day-to-day decisions had been considered and assessed.

Information about how to make a complaint was available. People confirmed they knew how to make a complaint or raise concerns.

We asked the registered provider to send us an action plan which outlined the actions they would take to make the necessary improvements. In response, the registered provider shared with us their action plan at regular intervals between August and September 2017detailing their progress to meet regulatory requirements and to achieve compliance with the fundamental standards. At this inspection some considerable progress had been made to meet regulatory requirements, however further improvements were still required, in particular relating to the registered provider’s quality assurance and governance arrangements.

The overall rating for this service is 'Requires Improvement.' However, we are placing the service in 'Special Measures.' We do this when services have been rated as 'inadequate' in any key question over two consecutive comprehensive inspections. The 'Inadequate' rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Melrose House provides accommodation, personal care and nursing care for up to 34 older people and older people living with dementia.

This inspection was completed on 19 and 20 September 2017. There were 18 people living at the service when we inspected.

A registered manager was not in post at the time of this inspection. The service was being managed by a team leader as the manager who had been appointed in May 2017 had left the service prior to our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Whilst improvements were noted since our last inspection in relation to some aspects of care provision, for example, care planning arrangements, medicines management, ensuring that bedrails for people using the service were now safe and fit for purpose, pressure relieving equipment was set correctly and infection control practices were now effective; quality assurance arrangements at provider and service level were not robust or as effective as they should be.

There was a lack of oversight by the registered provider to check and monitor the quality of the service provided or to check that the manager was making progress to the action plan so as to achieve compliance with regulatory requirements. It was evident from our findings at this inspection and following discussions with the registered provider that they had relied heavily on the manager to provide them with reassurance about their progress. Although the registered provider was told not to worry and everything was in hand, the registered provider had failed to monitor and evaluate this progress properly so as to assure themselves that sufficient improvements had been undertaken to their audit and governance arrangements and these were effective.

Robust procedures and processes that make sure people are protected from abuse and improper treatment had not been considered and followed by the manager. There had been a lack of preventative actions undertaken by the manager to keep people safe and to ensure that where there were concerns about a member of staff’s conduct appropriate actions were taken. We found that neither the registered provider, manager or staff fully understood their associated responsibilities and role in relation to preventing abuse of people using the service and to keep them safe.

Staff were aware of people’s individual risks and control measures to mitigate future risk had been explored and considered. However, improvements were needed to ensure the service’s fire risk assessment was updated and people’s individual emergency evacuation plans were accessible in the event of a fire or other emergency.

Training for newly employed staff was not up-to-date and it was difficult to determine what training had been attained by others employed at the service as certificates and evidence of training previously achieved was no longer available. Although staff stated they felt supported by the team leader, newly employed staff had not received a robust induction and staff had not received formal supervision.

Whilst some improvements were noted to the premises, further improvements were still required to maximise the suitability of the premises for the benefit of people living with dementia. This referred specifically to there being limited signage available to help people to orientate themselves around the service and there was a lack of sensory stimuli, such as orientation boards, information in an easy to understand format and memory boxes to help aid reminiscence.

Although all people using the service had a care plan in place, not all care plans had been reviewed and updated to accurately reflect people’s current care needs and improvements were required. Whilst people enjoyed a variety of ‘in house’ activities, improvements were needed to ensure that people living at the service had the opportunity to access their local community.

The deployment of staff was observed to be appropriate and there were sufficient staff available to meet people’s needs to an appropriate standard throughout the day and night. Part of this inspection was completed out of hours to ensure night staffing levels were appropriate. Suitable recruitment practices were in place and being followed so as to keep people safe. We observed that staff followed safe procedures when giving people their medicines and records now showed that people received their medicines as prescribed.

Staff had a basic knowledge of the Deprivation of Liberty Safeguards [DoLS] and the key requirements of the Mental Capacity Act [2005]. However, people were routinely asked to give their consent to their care, treatment and support by staff and people’s capacity to make day-to-day decisions had been considered and assessed.

People were supported to have enough to eat and drink. Suitable arrangements were in place to monitor and record people’s nutritional and hydration intake so as to identify at the earliest opportunity those people who were at risk. People received appropriate support where they required assistance to eat and drink. People were supported to maintain their healthcare needs and had access to healthcare services as and when required.

Staff knew the care needs of the people they supported and people told us that staff were kind and caring. Staff responded to people’s need for support and demonstrated appropriate concern for their wellbeing and people told us they were happy with the care and support provided by staff. People and their relatives told us that if they had any concerns they would discuss these with the management team or staff on duty. People were confident that their complaints or concerns were listened to, taken seriously and acted upon.

Melrose House provides accommodation, personal care and nursing care for up to 34 older people and older people living with dementia.

This inspection was completed on 7, 13 and 14 March 2017. There were 23 people living at the service when we inspected.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed back into ‘Special measures’ by the Care Quality Commission. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

A registered manager was in post at the time of this inspection and had been registered with us since 6 February 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was a lack of provider and managerial oversight of the service. Quality assurance audits carried out by the deputy manager were not robust, as they did not identify the issues we identified during our inspection and had not identified where people were placed at risk of harm or where their health and wellbeing was compromised. The provider and registered manager had not monitored progress in relation to the above so as to improve the quality and safety of services, and take appropriate action where progress was not achieved. In particular, the provider and registered manager had not ensured that information was accurate and properly analysed or that the person delegated to undertake this role was skilled and competent.

Suitable control measures were not put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered and risk assessments had not been developed for all areas of identified risk. The management of medicines was not consistently safe as people did not always receive their medication as prescribed and medicines were not stored as safely as they should be.

Whilst people told us they were safe and relevant agencies had been notified of any safeguarding concerns, the provider’s arrangements for the safekeeping of people’s money were not always appropriate. The procedures and processes relating to the financial management of people’s monies were not protected or safeguarded and significant improvements were required. As a result of our concerns we raised a safeguarding alert with the Local Authority.

Suitable arrangements were not in place so that dirty laundry was handled with care and eliminated the potential spread of infection. Poor infection control practices by staff were observed. Staff were seen to walk through the laundry as part of taking a short cut from the kitchen to the food storage cupboard. Laundry items and soiled laundry items were not segregated and water soluble red alginate bags were not being used. Some items of furniture and floor surfaces were also no longer impermeable.

Appropriate arrangements had not been put in place to ensure the newly appointed deputy manager or staff that had been promoted to a senior care role, had received a robust induction relating to their role and lines of responsibility. Although staff had received an annual appraisal of their overall performance, aims and objectives had not been set.

The premises were not ‘fit for purpose,’ particularly for people living with dementia. People were not living in a well maintained environment as many areas of the service required redecoration and some items of furniture, fixtures and fittings required repair or replacement.

People and their relatives were not fully involved in the assessment and planning of people’s care.

Not all of a person’s care and support needs had been identified, documented or reviewed to ensure these were accurate and up-to-date. Improvements were required to ensure that the care plans for people who could be anxious or distressed, considered the reasons for people becoming anxious and the steps staff should take to comfort and reassure them. Improvements were needed in the way the service and staff supported people to participate in community based social activities of their choice and ability and activities particularly for people living with dementia.

People did not consistently receive a service that was caring or care that met their individual needs. Improvements were needed to ensure people using the service were treated with respect and dignity. Although people had had their capacity to make decisions assessed, staff did not always understand the importance of giving people choices.

Arrangements were in place for staff to receive appropriate training opportunities and the majority of mandatory training for staff was up-to-date. Although staff told us that staffing levels at the service could be variable, staffing levels and the deployment of staff during the inspection were seen to be satisfactory. People were supported to have enough to eat and drink. People were supported to maintain good health and have access to healthcare services as and when required.

You can see what actions we told the provider to take at the back of the full version of the report.

Following our inspection to the service on 1, 2 and 5 September 2016, and as a result of repeated failings, an internal management review meeting was held on 5 September 2016, when it was agreed that a Notice of Proposal to cancel the provider’s registration would be issued. The overall rating for this provider was ‘Inadequate’. This means that it remained in ‘Special measures’ by the Care Quality Commission.

The provider shared with us their action plan on 6 November 2016. This provided sufficient detail outlining their progress to meet regulatory requirements. Following this inspection of 12 December 2016 a further internal management review meeting was held on 14 December 2016, whereby it was agreed that sufficient improvements had been made to not pursue our action to cancel the provider’s registration.

This inspection was completed on 12 December 2016. There were 22 people living at the service when we inspected.

The service had a manager in post. They were not yet formally registered with the Care Quality Commission but had submitted their application to be registered with us and were awaiting their ‘Fit Person Interview’. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

We found the provider and manager had made some progress to address previous identified shortfalls, however there were still areas that had not been satisfactorily addressed and these had not been picked up as part of the provider’s quality assurance arrangements.

Suitable control measures were not always in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered. The management of medicines was not safe as people did not always receive their medicines as prescribed.

Improvements were required to ensure that staff received a robust induction for their role and responsibilities. Furthermore, improvements were required to make sure where topics were discussed as part of formal supervision arrangements, actions were not recorded and addressed. Aims and objectives were not set as part of annual appraisal procedures.

People told us the service was a safe place to live and that there were sufficient staff available to meet their needs. Staff understood the risks and signs of potential abuse and the relevant safeguarding processes to follow.

Appropriate arrangements were in place to recruit staff safely so as to ensure they were the right people. Staff were able to demonstrate a good understanding and knowledge of people’s specific support needs.

Staff demonstrated a good understanding and awareness of how to treat people with respect and dignity. The dining experience for people was positive and people were complimentary about the quality of meals provided. People received appropriate support to have their social care needs met. People told us that their healthcare needs were well managed. Care plans accurately reflected people’s care and support needs.

Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been made in their best interests. The manager was up-to-date with recent changes to the law regarding the Deprivation of Liberty Safeguards (DoLS) and at the time of the inspection they were working with the local authority to make sure people’s legal rights were being protected.

Staff were friendly, kind and caring towards the people they supported and care provided met people’s individual care and support needs.

People and their relatives told us that if they had any concern they would discuss these with the management team or staff on duty. People were confident that their complaints or concerns were listened to, taken seriously and acted upon.

Following our inspection to the service in March 2016, an Urgent Notice of Decision was issued to the registered provider advising that no further admissions could be made to the service without the prior agreement of the Care Quality Commission (CQC). The overall rating for this provider was ‘Inadequate’. This means that it was placed into ‘Special measures’ by CQC. In addition, the Care Quality Commission met with the registered provider on 11 April 2016 to discuss our on-going concerns. During the meeting the registered provider and registered manager gave an assurance that things would improve.

This inspection was completed on 1, 2 and 5 September 2016. There were 23 people living at the service when we inspected.

The overall rating for this provider is still ‘Inadequate’. This means that the service remains in ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Because the service was in special measures already we inspected within the six months timeframe. Insufficient improvements had been made; we are now taking action in line with our enforcement procedures.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was a lack of provider and managerial oversight of the service. Quality assurance checks and audits carried out by the registered manager were not robust, did not identify the issues we identified during our inspection and had not identified where people were put at risk of harm or where their health and wellbeing was compromised. There was a reactive rather than proactive approach by the management team which meant that people did not receive a consistent safe and appropriate service. Lessons had not been learned and several areas of improvement had not been sustained in the longer term.

Staff were able to demonstrate an understanding and awareness of the different types of abuse and how to respond appropriately where abuse was suspected, however the registered manager had failed to implement robust procedures and processes to make sure that people using the service were safeguarded and protected from abuse.

Suitable control measures were not put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered. Risk assessments had not been developed for all areas of identified risk and had not always been completed to determine that these were suitable for the individual person so that any risks identified were balanced against the anticipated benefits. The management of medicines was not safe as people did not always receive their medicines as prescribed.

People did not think that there were sufficient numbers of staff available to meet their needs. Our observations showed that staffing levels and the deployment of staff were not always suitable. Staff did not always have time to spend with the people they supported to meet their needs and the majority of interactions by staff were routine and task orientated. People’s comments about the care and support they received were variable. Whilst some staff’s interactions with people were positive and staff had a good rapport with the people they supported, this was in contrast to other observations. These showed that some staffs practice required further improvement and development.

Suitable arrangements were not in place to ensure that the right staff were employed at the service. The implementation of staff training was not as effective as it should be so as to ensure that staff knew how to apply their training and provide safe and effective care to the people they supported. Robust systems were not in place for newly employed staff to receive a thorough induction. Although staff had received appropriate training relating to manual handling, staff did not recognise the importance of safe manual handling procedures in line with people’s specific needs.

People’s care and support needs had not always been identified and documented as required and reflected in their care plans. Improvements were required to ensure that the care plans for people who could be anxious or distressed, considered the reasons for people becoming anxious and the steps staff should take to comfort and reassure them. Significant improvements were needed in the way the service and staff supported people to lead meaningful lives and to participate in social activities of their choice and ability. Assessments had been carried out where people living at the service were not able to make decisions for themselves, however the arrangements for the use of covert medication were poor and ‘best interest’ meetings to evidence decisions had not been considered.

The dining experience for people was positive and people had their nutrition and hydration needs met. People were supported to access appropriate services for their on-going healthcare needs. Where appropriate people were enabled and supported to be as independent as they wanted to be and people were treated with privacy, dignity and respect. People knew how to make or raise a concern or complaint.

You can see what actions we told the provider to take at the back of the full version of the report.

The inspection was completed on 29 March 2016 and 31 March 2016. There were 32 people living at the service when we inspected.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by the Care Quality Commission. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was a lack of provider and managerial oversight of the service as a whole. Quality assurance checks and audits carried out by the registered manager were not robust, did not identify the issues we identified during our inspection and had not identified where people were put at risk of harm or where their health and wellbeing was compromised.

Suitable control measures were not put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered. Controls to manage the risk from hot water were not in place and therefore increased a scalding risk to people using the service. Safety checks relating to the service’s gas and electrical installations had not been completed at suitable intervals to ensure that these were safe. Individual Personal Emergency Evacuation Plans (PEEP) were not in place to respond effectively to health and safety incidents and other emergencies that may occur. Equipment within the kitchen and adjoining utility area were not properly maintained and people did not always have access to an appropriate supply of hot water.

People did not think that there were sufficient numbers of staff available to meet their needs or their relative’s needs. The deployment of staff was not appropriate to meet the needs of people who used the service and required reviewing so as to ensure people’s care and support needs were met. Staff did not have time to spend with the people they supported to meet their needs and the majority of interactions by staff were routine and task orientated. Suitable arrangements were not in place to ensure that the right staff were employed at the service.

The implementation of staff training was not as effective as it should be so as to ensure that staff knew how to apply their training and provide safe and effective care to the people they supported. Not all staff had received regular supervision or an annual appraisal. Formal support arrangements were not always in place for staff and people did not benefit from a well-supported staff team through appropriate training and supervision.

People did not always receive care that was responsive to their needs or care that was carried out in a person centred way. This was because staff shortages and poor deployment of staff at times meant that staff’s approach was often task focused and routine based.

While formal arrangements were available to assess the needs of people prior to admission, these had not always been conducted by the service, particularly for people admitted to the service on respite from hospital. Not all of a person’s care and support needs were identified and documented. Improvements were required to ensure that the care plans for people who could be anxious or distressed, considered the reasons for people becoming anxious and the steps staff should take to comfort and reassure them. Significant improvements were needed in the way the service and staff supported people to lead meaningful lives and to participate in social activities of their choice and ability.

Although there was a complaints system in place, management arrangements to investigate complaints thoroughly and to evidence outcomes were inconsistent and the provider’s policy and procedures had not been followed.

Staff were able to demonstrate an understanding and awareness of the different types of abuse and how to respond appropriately where abuse was suspected. Arrangements for medicines management at the service were safe and ensured that people received their medication as they should.

Despite variable comments from people about the quality of meals provided, the dining experience for people was positive and people had their nutrition and hydration needs met. Appropriate assessments had been carried out where people living at the service were not able to make decisions for themselves and to help ensure their rights were protected.

You can see what actions we told the provider to take at the back of the full version of the report.

We spoke with a number of people living in Melrose House and a visiting relative. People were happy with the care and support provided and thought that the staff were kind and responsive.

We found that the service was being maintained to a better standard of cleanliness. The right guidelines and suitable procedures were in place to ensure that people were protected by better levels of infection control being maintained.

Staffing levels were being monitored more closely. Better levels of staffing were being maintained to ensure that people were cared for safely.

People praised the staff at the service and made comments such as, "They are all good, kind and they look after me well." We found that staff were now better supported through induction, supervision and ongoing training.

We found that the quality and safety monitoring of the service had improved, but that further work was needed to provide a fully robust system. People now had more opportunities to express their views on the service.

We found that the service needed to take action in some areas to improve the quality of care and service provided to people. People needed to be more involved in saying how they wished their needs to be met and in ongoing reviews of their care needs. Peoples' care plans needed to be more consistent and in some cases more comprehensive to ensure that people's individual needs were understood and met.

Staffing levels/deployment needed to be improved to ensure that staff are readily available when needed and to provide better opportunities for stimulation and activity.

People praised the staff at the service and made comments such as, "They are a good team here and they look after me well." We saw that staff had a good relationship with people and treated people using the service with kindness and respect. We did find however that improvements were needed to ensure that staff were properly trained and supported in carrying out their role.

We found that the overall quality and safety monitoring of the service needed to be improved, but that in many instances improvements were in hand.