- Care home
Warm Melody Retreat
Assessment report published 14 August 2025
Contents
Ratings
Our view of the service
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.
People's experience of this service
People did not always feel safe care and supervision was delivered during the night. A person when referring to the fire alarm commented, “It’s been going for months, it’s driving me crazy.” People said there were enough staff to support them in the home but did not feel there was enough support when wanting to participate in outside activities.
People told us staff helped them to meet their basic needs, and they did not do long-term planning or set goals for them. “The [Warm Melody Retreat] staff don’t support me to go out, I organise things myself.” “When I first moved in it was lovely, but it’s changed. They [home manager] don’t treat me like a professional, but like a friend. They tell me off and are rude. [Name of home manager] hung up on me yesterday when I rang her. They always say, "You’re bombarding me", when I ask them anything. I feel like I’m walking on eggshells around them.”
“At first, I thought they (staff) were picking on me, but it's just how they are. I need tough love. They are my next of kin and [name of home manager] is my mum. [Name of care worker] is like my mum too.”