Updated 12 November 2024
Date of assessment: 14 November 2024.
Warm Melody Retreat is a residential care home for up to 4 adults with mental health needs. We carried out an assessment due to concerns about unlawful restraint. At the time of our visit there were 3 people using the service and only 1 person received the regulated activity.
The assessment was prompted in part due to concerns received about disproportionate use of restraint. A decision was made for us to inspect and examine this concern. We found disproportionate use of restraint by staff. The provider responded by implementing immediate safety measures and ensured staff received updated training.
Risk management and person-centered care were lacking. The service did not consistently provide person-centered care or uphold the Mental Capacity Act. Risk assessments were not collaboratively developed, and recruitment and staff training needed further improvement. While infection control and medication management procedures were sufficient and followed by staff, premises maintenance was inconsistent. Essential safety checks were completed.
There was a lack of managerial oversight. A development plan covering 2024 to 2025, addressed some of the concerns found during this visit but it lacked clear objectives and timescales. The service was in breach of regulations relating to person centred care, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, staffing, good governance and notifications.
We have asked the provider for an action plan in response to the concerns found at this assessment.