Melton Care Services Limited

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• 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 newly registered 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.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 59 (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. Whilst lessons were learnt to continually identify and embed good practice, this needed to be strengthened.

The provider’s management, oversight, and leadership supported the service in learning from incidents and mistakes. However, some shortfalls were identified. For example, a senior manager reviewed the electronic care monitoring data to check care calls were being provided in line with people’s planned care calls. The last 3 months of data identified the same shortfalls. This raised concerns about the effectiveness of the registered manager's actions to make improvements. There was no evidence that the senior manager had followed up or exercised oversight of the registered manager's actions. This was discussed with the management team, who told us they had daily contact but did not always record their discussions and actions.

Upon reviewing other information, including care package reviews, we found when concerns were raised about care delivery, these had not been recorded or treated as complaints. Although actions had been taken to address and resolve these issues, this meant there were missed opportunities for wider learning, including the identification of themes, patterns, and trends. The management agreed this was a recording issue and would make improvements.

People told us they found any concerns or complaints raised were quickly responded to and resolved. A person said, “Yes, the office staff seem to be approachable and listen, I have never had a big problem with them, whatever I have asked, they have tried to sort it out for me.”

Staff were able to explain how they would report accidents or incidents. Staff informed us that there were good channels of communication among themselves and with the management team. This included staff meetings and supervision, where any improvements to care delivery were discussed. A sample of meeting records confirmed what we were told.

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

Whilst pre-assessments were completed before people received care and support, staff training needs had not always been considered to ensure staff had the required knowledge to support people safely and effectively.

The staff training matrix identified staff had not received training in diabetes care, sepsis and supporting people with behaviours of concern. From reviewing a sample of people’s care records, these specific health conditions and care and support needs were identified during people’s pre-assessments. We discussed this with the management team who agreed to review their training programme and include this training.

People and relatives confirmed they were involved in a face-to-face pre-assessment before care was provided. This included involvement in developing care plans. A relative told us how the manager visited [person] at home following a hospital discharge and completed an assessment. People confirmed new staff shadowed experienced staff and how they received care and support from a core group of consistent care staff.

Staff informed us that they provided care to a regular group of people, which supported consistency and continuity in care delivery. Staff told us that new care packages and/or changes to people’s needs were effectively shared with them.

Processes had been developed to share important information with others, such as ambulance and hospital staff to support people to receive consistent care.

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.

A review of the provider’s systems and processes found where safeguarding concerns and allegations had been reported, action had been taken to investigate and reduce the risk. However, we did identify a safeguarding concern during 2025 that had been reported to the local authority safeguarding team as required, but not to us, the Care Quality Commission (CQC). The registered manager was not in post at the time, and they were found to be knowledgeable of their safeguarding responsibilities.

People told us they had no concerns about safety and were complimentary of the staff’s approach to care delivery. People confirmed staff wore a uniform and badge to identify themselves. A relative said, “On the odd occasion when [person] doesn’t feel happy, they will say, and if they are still unsure, they [registered manager] won’t send them [staff] again. They are very good, good quality carers.” A person said,“ Yes, they [staff] are very, very good at their job, so I am quite happy with the service they give. I am clean and safe. The question [of feeling unsafe] hasn’t arisen, but I would tell the office.”

The provider ensured staff received safeguarding refresher training and had access to the provider’s safeguarding policy and procedure. Staff were knowledgeable about what safeguarding means and their responsibilities in protecting people from abuse and avoidable harm. A staff member said, “Safeguarding is about our responsibility to protect our service users from neglect, abuse, exploitation and allow them to live with independence, dignity, and respect. I have a responsibility to report any concerns.”

The provider did not consistently work well with people to understand and manage risks. We identified shortfalls in risk management and mitigation. Risk assessments were found to be largely generic and not personalised. Not all risks had been assessed and planned for. No person had come to harm, but people were at increased risk of harm.

For example, a person had a catheter, but signs and symptoms of a catheter-related infection were not documented in the care plan, and no specific risk assessment was in place. A Staff member was able to describe the care required, including the actions to be taken if concerns were identified. However, we could not be assured that all staff were this knowledgeable. Without clear, detailed guidance meant the person was at increased risk of harm.

Another person was known to be at increased risk of developing sepsis, yet there was no guidance for staff within the care plan of signs and symptoms and actions required if concerns were identified, nor any associated risk assessment. This meant there was an increased risk of avoidable harm.

Some people experienced periods of emotional distress and presented with behaviours of concern that put them at risk. There were no positive behavioural support plans that provided staff with guidance on how to safely manage these risks or strategies to reduce such behaviours safely and effectively.

We were also concerned that staff had not received training in known risks of sepsis and managing distressed behaviours. This compromised both people's and staff’s safety.

Risks associated with the environment for people/care staff had been assessed and planned for. Staff were provided with guidance on how to safely manage equipment.

People and relatives were confident that staff supported them well. A relative said, “[Staff member] is very good with [person] and will do anything for them. The carer has a certain way with them. I have a lot of confidence in the carer. It makes a lot of difference if you get the same carers.”

Staff informed us about the improvements made to risk management. A staff member said, “Since [name] the manager has taken over, there have been many improvements, one of which is care plans being updated regularly, and risk assessment being brought up to date, and the staff dealing with this are very receptive to feedback and make any changes necessary. This enables me to support the clients better and meet their care needs and risks.”

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

Risk assessments were in place to ensure the environment was safe for people and staff. This included information on smoke alarms and how to switch off the water and gas supply in an emergency.

Staff promoted people’s safety and independence by making referrals to external health and social care professionals for equipment, such as aids and environmental adaptations.

Staff felt safe working in the community. New staff shadowed experienced staff before working independently.

The provider had a loan working policy and an out-of-office procedure staff could use to contact for support or advice.

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. However, the staff training matrix identified the following training was not provided, despite people having these health conditions and care and support needs. Diabetes, sepsis and behaviours of concern. We discussed this with the management team who agreed to review their training program and add this training.

A review of staff recruitment procedures identified that some improvements were required. Staff were not required to complete a health questionnaire, and the interview questions used limited the provider’s opportunities to fully assess applicants’ suitability for the role. One staff member’s application had gaps which had not been followed up. We discussed this with the management team, and immediate improvements were made.

Staff received regular opportunities to discuss their work, training and development needs. Regular spot checks were completed to ensure the quality and safety of care provided by staff. Staff competencies were completed in areas such as moving and handling to ensure staff were competent and knowledgeable to safely support people. Staff meetings were also conducted and used as an opportunity to discuss staff training, development and competency.

Staff were positive about the support they received. A staff member said, “Training is usually online which is great as it means we can work at our own pace. We are spot-checked regularly every 3 months. We also have supervision and wellbeing meetings.” Another staff member said, “Our manager is a very approachable and is very easy to talk to and listens to any concerns that we have and takes them seriously.”

People and relatives were positive and complementary about the experience, the knowledge, and the skills of the staff. There had been no missed calls and care calls were largely at the agreed time. Where calls had been late, these overall remained within the agreed timescales that allowed 15 minutes either side of the scheduled call time. Travel time was allocated and staff confirmed this was sufficient.

People told us that if staff were running late, they mostly received a call advising them of this. The management team informed us about the impact of the new local bypass on unpredictable travel times.

Overall, people confirmed staff attended for the duration of the call. However, the electronic call monitoring data showed examples of care calls being shorter than the allocated time. The director for the service who reviewed this data told us how staff emailed the management team if they left before the end of the call, and the reason for this. This evidence was not provided within the electronic call monitoring analysis, but the director confirmed this would be added.

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.

Staff training records confirmed staff had completed infection prevention and control training. Staff told us they had access to personal protective equipment (PPE).

Staff conducted spot checks of records, which included observations and discussions with staff about infection prevention and control practices and expectations.

People told us they had no concerns about infection, prevention and control practice. People and staff confirmed PPE was worn and disposed of safely.

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.

Where people required support with their prescribed medicines, this was recorded in a care plan and a generic risk assessment. Care plan guidance for staff included the level of support required, such as full assistance, prompt or supervision, where the medicines were stored and the person’s preference of administration. Also recorded were the support provided by family or others, such as ordering and collecting prescriptions.

Where people received support with their medicines, they were satisfied staff provided support safely. One relative raised a concern about the gap between the person’s medication administration. The person’s care review highlighted the importance of a 4-hour gap, and the care call times were reviewed and adjusted accordingly. We reviewed the person’s medication administration records, which confirmed a 4-hour gap as required.

Staff had received training in the management and administration of medicines, including having their competency assessed. The electronic care‑record system was able to immediately flag and alert the management team to any missed medicines. The live medicines system was reviewed, and it confirmed that people had received their prescribed medicines when required.