Melbreck

Melbreck is a nursing home providing personal and nursing care to up to 26 people with learning disabilities and complex needs in one adapted building. At the time of our inspection there were 23 people living at the service. The service was a large home, bigger than most domestic style properties and situated in a rural location.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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

Risk to people’s safety and well-being were managed although records of healthcare concerns were not always clearly recorded to ensure action taken could be fully monitored. This monitoring was made more difficult by the high use of agency nurses. Although records of people’s care were updated they were not always clearly organised to ensure staff could access information easily. We have made recommendations regarding these concerns.

Staff were aware of their responsibilities in relation to keeping people safe and robust recruitment systems were in place. Contingency plans ensured that people would continue to receive a safe service in the event of an emergency. People lived in a safe and homely environment which was suited to their needs.

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. Choices of foods were available to people and staff were knowledgeable about people’s dietary requirements. People were supported to see healthcare professionals when required. Staff received training, induction and on-going supervision to support them in their roles.

Staff supported people with kindness and respected their privacy. Staff understood the need to maintain and develop people’s independence wherever possible. People and their relatives were fully involved in their care and staff were knowledgeable about people preferences and communication styles. A range of activities were provided to people with an emphasis placed on community activities.

There was an open and positive culture developing within the service. Staff shared the same values and wanted to provide a positive experience for people. People, relatives and staff had the opportunity to contribute to the service and felt their ideas were listened to.

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 with the Well-Led domain rated as Inadequate (18 January 2019).

Following the last inspection we issued warning notices in respect of people’s safe care and treatment and the governance of the service. The provider completed an action plan to show what they would do and by when to improve. At this inspection we found improvements had been made. The requirements of the warning notices had been met and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This service was set up and registered prior to Building the Right Support and Registering the Right Support and it is not the type or size of service we would be registering if the application to register was made to CQC today. This is because it does not conform to the guidance as it is very difficult for large services for people with learning disabilities to meet the standards.

This inspection took place on 30 October 2018 and was unannounced.

There was a registered manager in post who supported us during the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At our inspection on 19 and 25 July 2017 we rated the service 'Requires Improvement' and identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, consent, person-centred care and good governance. At our inspection on 27 March 2018 we found that despite some improvements having been made, the provider had not met the legal requirements in relation to risk management, person-centred care and staffing. We made a recommendation with regards to the governance of the service.

Following both inspections, 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. At this inspection we found that although further improvements had been made in some areas, there were continued breaches of regulations. These related to the management of risk, healthcare monitoring, family involvement, responding to complaints, record-keeping and good governance.

There were continued risks to people’s safe care and well-being as healthcare needs were not consistently monitored. The supervision and competence monitoring of clinical staff was not consistent and effective. The service had not always fully involved families in their loved one’s care and complaints were not always recorded. People’s care records were not always accurately maintained and quality audits did not always identify shortfalls in the service. There was a lack of support for the registered manager from the provider. The policy review process had negatively impacted on the trust some relatives had in the service.

Sufficient staff were deployed to meet people’s needs. Robust recruitment processes were in place to ensure only suitable staff were employed. Staff demonstrated a good understanding of their responsibilities in safeguarding people from potential abuse. Safe medicines processes were in place and staff competence in supporting people in this area was assessed. Accidents and incidents were reviewed and action taken to prevent them happening again. People lived in a safe environment and regular health and safety checks were completed. Staff followed safe infection control procedures. The provider had developed a contingency plan to ensure that people's care would continue to be provided in the event of an emergency.

People were supported by staff who received an induction into the service and regular training. People lived in an environment which was suited to their needs. In some areas of their care people had access to healthcare professionals to support them in maintaining good health. People’s nutritional needs were met and people were provided with a choice of healthy foods. People’s legal rights were protected as the service was working in line with principles of the Mental Capacity Act 2005.

People were supported by individual staff who showed kindness and care. People's dignity and privacy was respected by staff and people were supported to maintain and develop their independence. Staff had a good understanding of people's communication needs and interacted with people in a positive manner. Visitors were made to feel welcome and there were no restrictions on visiting times. In some areas care records reflected people’s needs and end of life care plans were sensitively written. Significant improvements had been made in the activities available to people which had impacted positively on their well-being.

Staff told us they felt supported by the registered manager and were able to speak openly regarding any concerns. There was a good sense of team work and a positive approach from staff. People’s opinions of the service were monitored through person-centred reviews and keyworker involvement. The CQC had been notified of significant events in line with regulatory requirements.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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. At this inspection, we found that despite some improvements having been made the provider had not met the legal requirements in relation to risk management, person centred care and staffing. We have also made a recommendation with regards to the governance of the service.

Melbreck is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Melbreck accommodates up to 26 people with learning disabilities and complex needs in one adapted building. At the time of our inspection there were 26 people living at the service.

There was a registered manager in post who supported us during the 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.

Risks management plans were not always followed to ensure people’s safety and well-being were maintained. People’s weight was not always monitored to highlight concerns and people did not have regular access to a range of health care professionals. Clinical staff did not receive effective supervision and skills were not monitored. Access to activities within the community was limited and daily activities at home were repetitive. Quality assurance systems had not highlighted the above concerns to ensure that people received the care they required.

Staffing levels had increased and the way in which staff were deployed had changed. This meant that people’s day to day care was now provided in a more organised and timely manner. Care staff had access to the training they required and regular supervision was provided to support staff in their roles. Prior to starting work staff underwent robust recruitment checks to help ensure they were suitable to be employed at the service. Staff told us they felt supported in the roles and that the new registered manager had had a positive effect on staff morale and the culture within the service.

People received their medicines as prescribed and medicines were safely stored and managed. Staff knew people’s needs well and we observed positive interactions with people throughout the inspection. Assessments took place prior to people moving into the service to enable staff to better understand their needs. Detailed care plans were in place to support staff in providing people’s care and people’s independence was maintained. The registered manager had introduced person centred reviews to increase people’s involvement in their care.

People had a choice of nutritious foods and their dietary needs and preferences were known to staff. People’s cultural needs were respected and staff understood the importance of this. Systems were in place to ensure that the principles of the Mental Capacity Act 2005 were followed and people’s rights were respected. Staff understood their responsibilities in keeping people safe from potential abuse. Accidents and incidents were monitored to minimise the risk of them happening again.

People lived in a safe, clean and comfortable environment. Regular health and safety and maintenance checks were completed. A contingency plan had been developed which meant that people would continue to receive care in the event of an emergency. Safe infection control procedures were followed and cleaning schedules were in place.

Quality assurance systems had been effective in developing the service in some areas. Relatives told us that the new manager was approachable and they felt comfortable in raising any concerns. The provider had a complaints policy in place. Complaints were monitored, investigated and responded to in line with this policy.

During the inspection we identified three breaches of regulations. You can see what action we told the provider to take at the back of the full version of the report.

There was no registered manager 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. The registered manager had left the service in December 2016. At the time of our inspection the service was being managed by an interim manager and clinical operations manager who supported us during the inspection. We have been informed since the inspection that a new manager has been appointed.

There were insufficient staff deployed throughout the service to ensure people’s needs could be met. We observed people spent periods of time without staff interaction. Due to the high level of agency staff used people were not always supported by staff who knew there needs well. People’s nutritional needs were not always monitored to ensure they received safe care. We have made a recommendation regarding this.

There was a lack of stimulating activities available to people. People had limited access to community activities and activities within the service were repetitive. People’s rights were not always protected as the service was not consistently acting within the Mental Capacity Act 2005. Capacity assessments and best interest decisions completed were not always decision specific and Deprivation of Liberties applications did not always clearly highlight the restrictions in place.

The lack of good leadership after the departure of the registered manager had an impact across

key areas we looked at. It affected the safety of the home, how effective the home was at meeting people’s needs, and how well the home was led. Quality assurance systems were not always effective in identifying concerns and the lack of consistent leadership in the service had led to low staff morale and concerns regarding communication of changes taking place.

Staff had received safeguarding adults training and were aware of their responsibilities in protecting people. Records showed that where concerns were raised these were reported and investigated. Risks to people’s personal safety were assessed and control measures implemented to help keep them safe. Accidents and incidents were monitored and reviewed to minimise the risk of them re-occurring. The provider had developed a business continuity plan to ensure people would continue to receive safe care in the event of an emergency. Personal emergency evacuation plans were in place to guide staff in the support people would require should they need to evacuate the building.

People were supported to receive their medicines safely. Medicines were administered in line with prescription guidelines and were stored securely. Staff competency in the administration of medicines was assessed. People had access to a range of health care professionals and advice provided was followed by staff. People were provided a choice of food and drinks which was prepared in the line with the specific needs.

Staff received appropriate training, which was reflective of people’s needs, to support them in their roles. Regular staff supervisions were held to monitor staff performance. Prior to being employed staff underwent robust recruitment checks to ensure they were suitable to work in the service.

People were supported with kindness and compassion by staff who knew their needs well. However, the high use of agency staff impacted on the care people received. Staff were aware of people’s individual communication styles and supported their cultural needs. Care plans were detailed regarding the support people required and were regularly reviewed. People’s dignity was maintained and visitors told us they were made to feel welcome. A complaints log was in place which showed that formal complaints had been appropriately addressed and monitored. However, some relatives told us they did not always feel the service communicated well.

Records were securely stored in an organised manner. Notifications had been completed to inform CQC and other outside organisations when significant events occurred.

During the inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.