Melbourne House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service under the new provider. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager had a positive reporting culture; staff understood their responsibility to report and document where an incident or accident had taken place. The registered manager ensured they reported concerns promptly to the local authority safeguarding team.

People and their relatives were confident the service supported people safely and were responsive when they raised concerns.

The registered manager had a robust approach to the continual improvement of care quality. A proactive approach was taken to ensuring learning was taken from events. We saw the management team had implemented reflective practice for the staff team. This was shared during formal staff meetings and in the daily handover meetings.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People and their relatives were involved in planning their care and support needs. One relative told us, “Our family member has only been here a week, and staff come to us all the time to explain what is happening. We feel very well supported”.

The registered manager used a robust pre-admission tool, which allowed them to ensure they could meet people’s identified needs prior to them moving into Melbourne House. They ensured they worked in partnership with external health and social care partners, to achieve the best outcomes for people. Staff knew how to monitor people’s health conditions, to ensure timely referrals were made to other services. For example, where a person had experienced changes in their mobility and had been referred onto a specialist team for review.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Relatives told us they felt their family members were safe with staff, and any incidents were reported to them promptly and investigated. Everyone we spoke with told us they felt safe and well supported by the staff.

The registered manager used outcomes from safeguarding investigations to ensure lessons were learned and care quality was improved where any recommendations were made. Staff we spoke with understood the importance of upholding safeguarding standards and ensuring they reported events to the registered manager. There was a provider policy on the duty of candour. This policy guided the registered manager or nominated individual to tell the person (or, where appropriate their advocate) when something had gone wrong. We reviewed complaints that had been made and saw this policy had been followed.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff had received training on how to support people’s individual needs. Some people at the service could become distressed due to their dementia diagnosis. Staff had received training on how to support people when they became upset or anxious. We saw people were supported safely by staff during our time at the service. Staff were timely in their responses towards people to ensure any distress did not escalate.

People’s needs were clearly documented in their care plans, which meant staff had clear guidance on a person’s mental, physical, and social needs. We discussed improvements needed to risk oversight documents, for a person living with a stoma and a person living with wound management needs. The registered manager supplied updated documents at the end of the day of our visit, we were assured by their responsiveness.

Staff knew how to support people to manage risk. For example, where people lived with a risk of falls and required the support of staff for mobilising or moving from a chair to a bed with the assistance of equipment.

One relative gave positive feedback about the way staff supported their family member to reduce their risk of falls. They told us, “My family member has fallen a lot so they have been advised to support them in bed until they have been assessed for a specialist chair, so they can sit up safely.”

People we spoke with or observed appeared to be satisfied with their equipment provision and safety devices. We observed staff hoisting a number of people in the lounge, into wheelchairs to move them to the dining area. These manual handling procedures were carried out in a calm, efficient manner with kindly interactions between staff and people. People and their relatives told us they were able to communicate their needs, to ensure they received the right type of support.

We found personal emergency evacuation plans had been regularly reviewed, ensuring they fully considered the unique needs of people. Staff had clear processes in place for how to respond to an emergency event and the evacuation processes to follow, for example, in the event of a fire.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Some people showed the inspection team their bedrooms, which we saw had been personalised to their own tastes, with ornaments, photographs and personal items on the walls.

People had access to call bells to call for support if needed. Documentation showed the call bell system and linked sensors for falls management were well maintained, to ensure they were effective and reduced the risk of people experiencing harm. On the day of our visit, there was an intermittent fault identified with some of the call bells. The registered manager promptly arranged for a technician to visit, and this issue was resolved by the end of the day. People were not left at risk of harm, as the registered manager ensured they deployed staff to account for the fault. We were assured by their responsiveness.

People and relatives told us that the call bells in their bedrooms were working and accessible, and staff responded to them promptly. One person said, “Usually they will answer it quite quickly it depends on how busy they are, sometimes you have to wait a while. I wait till a buzzer has just been answered and then I press mine and that seems to work well for me.”

The provider had a service improvement plan, detailing the ongoing refurbishment works. Where these works had been completed, we found a high quality, welcoming, safe environment for people.

The maintenance team described a clear process for monitoring environmental safety concerns. We saw there had been regular checks to ensure the home was safe in the event of a fire (for example, by carrying out practice drills.) Systems were in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria (like legionella.) The gas heating system was regularly serviced to prevent harm to people.

Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain how people would be supported to move into a safe space.

Bedrooms we observed contained furniture which was secured correctly to the wall as required under Health and Safety Executive (HSE) guidance. The registered manager and maintenance team completed regular audits of all bedroom furniture, to ensure this was safe and fit for purpose.

The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment.

Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the HSE.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People and their relatives gave positive feedback in response to staff numbers, availability, skills, and their caring approach. One person said, “Yes, I think there are enough staff, I am independent, so I don’t need much help, but if I do, they are there.”

We saw from our observations and staffing rotas; there were sufficient staff available to safely provide support to people. Staff were deployed effectively around the building, to provide timely support for people.

We saw staff were suitably trained to complete their roles. Staff used their training and skills to respond effectively to people’s needs. Once staff were trained, there were clear ongoing processes to assess their competency. If needed, further support and training was then given to improve staff skills.

If staff were not providing the expected level of care, there were clear processes to monitor and improve their performance. Staff we spoke with felt confident about the staffing levels, ensuring they could respond to people’s immediate needs. Staff told us they received regular opportunities to meet their line manager on a one-to-one basis for supervision. These meetings offered staff the opportunity to feedback about their experiences and request further guidance and training if needed.

Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and their relatives told us that the home was kept clean. People told us that staff wore personal protective equipment as needed. Staff knew which personal protective equipment they should wear and when. Staff knew how to put on and dispose of this equipment, in a safe way. This protected people from the spread of infection.

Staff had received food hygiene training. They were able to explain what actions they took to reduce the risk of food borne infections. We saw the kitchen was managed in a hygienic way to ensure people were not exposed to the risk of food borne infections. The most recent check from the food standards agency had rated the service 5, very good, on 7 August 2025.

Some people at the service used equipment (like walking frames, shower chairs or hoists). We saw these pieces of equipment were reviewed in daily walk arounds by the management team, to ensure deep cleaning took place.

There were clear processes and policies in place, to ensure people were protected from the spread of an outbreak or infection. If an infection outbreak occurred (for example diarrhoea and vomiting), there were clear processes in place to reduce the risk of this spreading to other people at the service. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People and relatives told us they had no concerns about the safe management of medicines at Melbourne House. People and relatives told us their taking of medicines was always supervised, and that staff gave their medicines at regular times, and as their prescription required.

We observed a clinical staff member during the medicines round, and they showed confidence and followed best practice guidelines when administering and recording medicines. The clinic room was kept clean, tidy and organised. Staff knew who to report medicine concerns to. For example, if they felt a person’s medicine was no longer effective, they understood where to document this, and which health professionals to contact.

Some people required ‘as needed’ medicine and staff had clear written guidance on how this should be administered. For example, multiple people required pain relieving medicines to be administered ‘as needed.’ We saw the documentation for these medicines clearly explored the reasons why people had required these medicines, and the records reflected this.

Some people required their medicines to be administered covertly. Covert medication is when staff administer medicine without the persons’ knowledge or consent; for example, by disguising it in food or drink without the person knowing. We found the relevant mental capacity assessment and decision-making documentation for this was in place.

Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff completed regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed. One area of particularly good practice was the prescribed creams trolley. We saw this was highly organised, with associated body maps in place, to ensure consistent application and to support good skin management for people.