Melwood Grange

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 inspection for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (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 fostered a proactive and positive culture of safety, grounded in values of openness and honesty. All accidents and incidents were recorded and closely monitored, with actions taken to mitigate risks to people using the service. Where necessary, incidents were reported to relevant external agencies.

The registered manager had implemented effective systems to ensure that all accidents and incidents were regularly analysed. This analysis aimed to identify any emerging themes or patterns, enabling the service to mitigate further risks and improve the quality of care provided.

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

Assessments were carried out before people moved into the home. As the home had only been operational for a year, some residents had transferred from a smaller home. These assessments drew upon information provided by families, health and social care professionals, relevant representatives, and the individuals themselves. This approach allowed staff to develop detailed care plans offering clear guidance on how best to support each person.

Staff worked in close partnership with external professionals, including GPs and district nurses, to make certain that residents received safe care and treatment. Professionals who engaged with the service spoke highly of the staff’s communication. One professional commented: “The home is consistently welcoming, and staff have been helpful and cooperative during my visits. Communication with the service has been appropriate and timely.”

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.

People generally reported feeling safe in the home. However, it was noted that 1 person expressed feeling unsafe in their room; this concern was promptly brought to the attention of the registered manager, who was asked to take steps to mitigate the risk.

All staff received training in safeguarding and demonstrated a sound understanding of the procedures, including recognising and reporting signs of abuse. They were knowledgeable about the appropriate channels for raising concerns, whether within the service itself or, if necessary, with external bodies such as the local authority, the police, or the Care Quality Commission (CQC). Staff were also supported by clear safeguarding policies and procedures, which enabled them to act confidently and appropriately when concerns arose.

People's freedom could only be restricted for care and treatment if a legal process, such as the Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005, was in place. The provider regularly reviewed and monitored these safeguards, ensuring that each person's care plan included details regarding their mental capacity and any relevant DoLS authorisations. Care plans clearly explained what these safeguards meant for people’s support.

The provider collaborated with people to understand and manage risks through a holistic approach. Staff delivered care that was safe, supportive, and responsive to people's needs, enabling them to pursue activities important to them. Risk assessments were clear, comprehensive, and regularly updated, containing sufficient detail for staff to provide safe care and address potential risks such as falls, skin damage, or choking.

It was observed that risk assessments for people exhibiting emotional distress needed to be more robust and contain additional information to help staff monitor and manage these risks effectively. People identified as at risk of choking received modified foods such as pureed diets and fluids, following assessments by speech and language therapists. These modified meals were prepared in the kitchen and labelled with the people’s name before being sent to the appropriate floor, thereby reducing the likelihood of incorrect food consistencies being provided.

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

People told us the care home was a comfortable place to live. The environment was free from unnecessary slip or trip hazards. which enabled people to move freely and safely around the care home.

Fire safety measures were in place, including risk assessments, and people and staff were involved in practice evacuations. Legionella risk management systems were in place and hazardous substances were securely stored.

During the inspection, dried foods in the kitchen were found to be improperly stored and labelled, not meeting recommended standards. Senior staff explained that appropriate containers had been ordered, but as of the visit, these had not yet arrived, and the inadequate storage was still being used.

The provider ensured that care was delivered by qualified, skilled, and experienced staff who received appropriate support, supervision, and development. Safe recruitment procedures were in place, ensuring staff had the correct requirements to care for people living in the home. New staff received an induction and there was an ongoing programme of regular training for all staff.

A staffing dependency tool was in place to help determine appropriate staffing levels based on people’s needs. However, there was some mixed feedback about staffing levels. Some staff felt on occasions they felt short-staffed whilst others felt there was enough staff.

People also gave feedback about staff and at times they felt more staff were required but acknowledging they were happy to wait for carers to come and support them.

Family members also felt at times staff were rushed particularly during mealtimes. We gave this feedback to the registered manager and staff told us there was a plan to review the staffing model for the afternoon shift.

The provider did not consistently evaluate or address infection risks, some staff were manually crushing bedpans and disposing of contents via toilets. Some staff reported that manual crushing of infectious material was standard practice at the home, although this did not align with recommended infection control protocols. The provider had not taken appropriate action to ensure staff were following the correct policy.

The environment, including kitchen areas, was maintained in a clean and orderly manner. Staff had access to personal protective equipment (PPE), and its use was observed to be appropriate.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There was no documented evidence of risk assessments or consultation with prescribers and pharmacists regarding the practice of crushing medicines or administering them in food for 2 people when the inspector reviewed care plans during the site visit.

During a review of controlled drugs, discrepancies were identified in the drug counts. Senior staff attributed these anomalies to errors within the electronic systems which the provider was aware off.

People were supported to self-administer their medicines, but thermometers were not provided in their rooms to monitor the storage conditions of their medication.

The management of “when required” (PRN) medicines was safe, with clear protocols in place to guide their administration. Nevertheless, some staff interviewed reported being unaware of how to access these protocols, making them unavailable when needed.

One person was currently receiving prescribed medication in a crushed form, mixed with water. This approach had been taken due to the person’s lack of capacity to make informed decisions regarding his medication. However, there was no best interest’s assessment in place to justify the covert administration of medication. The provider took prompt action to address this issue when it was brought to their attention.

The home operated an effective process for ordering and delivering medicines, ensuring that people had a continuous supply. Medicines, including controlled drugs, were securely stored, with access strictly limited to authorised staff members.