Warm Melody Retreat

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.

At our last inspection we rated this key question good. At this inspection the rating has changed to 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 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People did not always feel safe care when supervision was delivered during the night.

In response to night time supervision the home manager stated, “Once [name of person]’s 1 to 1 is finished, and they [day staff] have done the cleaning, there isn’t much for the night staff to do. It’s okay if they [night staff member] sleep or watch TV.”

The home manager, when sharing their reflections about a safeguarding incident where restraint was used, acknowledged they had not responded well to the situation. They commented, “I need to step back, re-evaluate, get my confidence back and look at what I need to learn.”

The registered manager shared their reflections about restraint practices told us, “I understand we must not restrain people, and we must read our policy. We are going to the local authority to get further assistance in this area. We have now signed up with another care training provider and I am finding the right provider to conduct restraint training for staff within the next week.”

Care staff told us they received safeguarding training and described the different types of abuse people could experience and the procedures they had to follow to report them.

This assessment was prompted by an incident involving alleged improper restraint, leading to a physical abuse allegation. We found management lacked consistent adherence to safeguarding and restraint policies and procedures which compromised people’s safety.

The local authority confirmed staff’s action in the incident amounted to physical abuse, and our findings revealed disproportionate use of restraint.

The home manager frequently communicated with health and social care professionals regarding a person with complex health needs. However, the person consistently refused to take their prescribed medicines and make necessary dietary changes. This placed them at significant risk of harm. Despite these on-going concerns, the risk assessment was not updated for a period 10 months to reflect these specific risks. As a result, there were no documented instructions or clear plan to guide staff on how to safely manage the situation.

There were missed opportunities to update risk assessments and care plans to enhance people’s safety. In August 2024, a person communicated suicidal intentions to both their GP surgery and Crisis Line. This new information was not documented in their care plan dated 2020 to 2024. In addition, their 'mental health distress' risk assessment revealed it was last updated in July 2024. This showed the service did not always do all that was reasonably practicable to mitigate risks.

People were not always involved in managing risks and in developing their risk assessments. There was no evidence in care records viewed to show pre-admissions assessments had been completed and captured people’s views about risk to their health and welfare.

Staff did not promote positive risk-taking in a safe way. This was evident when reviewing the incident where unlawful restraint practices was used by staff when trying to support a person.

Safeguarding concerns were not consistently documented, and insufficient action was taken to prevent recurrence.

After our visit the registered manager sent us an action plan which outlined the actions taken to ensure all staff understood and follow the service’s restraint policy and procedures, received relevant training and what lesson had been learnt from this incident.

A person expressed concerns about night time supervision. However, after our site visit the provider sent us documentary evidence that showed the person was regularly supervised during the night.

Staff were aware of their responsibility to protect people from infection and medicines were kept securely and were safely administered.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

A person when referring to the fire alarm commented, “It’s been going for months, it’s driving me crazy.”

The registration manager informed us the care home was scheduled to undergo refurbishment, and the work will address all maintenance issues we have found.

In response our observation of an individual's room being cold and the person telling us the heater in their room was not working, the home manager stated, "The heater was functioning, but the person’s preference was to have the room temperature at a certain level."

The environment looked worn and in need of redecoration.

A person's bedroom was cold. We observed them wearing a winter coat while in their room. They told us they thought the heater in the room did not work and had raised this with the home manager.

Premises and equipment were not consistently maintained. A significant step existed between the lounge and kitchen, lacking sufficient warning signage to prevent people from falling. We noted the risk to people were minimum at the time of our visit as people living in the service were mobile and aware of the step.

Some kitchen cupboards were in a state of disrepair, with hinges coming loose.

Reasonable adjustments were not always considered for people with disabilities. The stairs and first-floor hallway were extremely narrow, presenting challenges for individuals with mobility limitations.

Despite having a contractor for fire safety assessments and maintenance, a persistent beeping sound emanated from a smoke alarm throughout our visit. People reported the alarm had been beeping for months. The beeping was audible in both occupied upstairs bedrooms, even with doors closed. The registered manager's response to the issue demonstrated a lack of urgency and failed to address the situation with appropriate action as it had not been reported to the relevant contractor.

The provider was in breach of regulation relating to premises and equipment.

Fire blankets and extinguishers were available in the kitchen and upstairs. Fire extinguishers had been checked in January 2024. The backyard fence had been heightened to deter unauthorised access and exit. The sharp knife drawer was kept locked to ensure people’s safety. The registered manager ensured compliance with essential safety checks, including gas safety, legionella testing, and electrical equipment testing.

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.

“I [registered manager] check their [staff’s] understanding of people’s care and support needs in supervision.

A staff member commented, "I believe we need face to face training, but we have not had any except face-to-face break-away techniques. I receive supervision every 2 months. It broadens my horizon and increases my knowledge, we cover everything.”

There were enough staff to provide care and support to people who were in the service at the time of our assessment.

Recruitment practices required further improvement as the home manager failed to adhere to the service's September 11, 2024, recruitment policy regarding interview practices. Interviews often neglected crucial checks like work history gaps and reference suitability. For example, gaps in employment without explanation were found in 2 out of 3 staff records viewed. A staff member's 7-year employment gap was insufficiently investigated. This jeopardised the service's ability to ensure staff recruited had the necessary experience and were of good character.

Staff with managerial responsibilities did not receive appropriate role specific training to enable them to support staff effectively. The registered manager claimed to have attended webinars during the last year but was unable to provide us with evidence to support this. The home manager's mandatory training was at the same level as care staff and was not role specific. This lack of specialised managerial training may have limited the home manager's ability to effectively support and guide staff in their roles, potentially impacting the quality-of-care people received.

Medicine competency assessments for 3 staff members relied on identical, generic statements, and failed to record specific observations. This "tick-box" approach hindered the service's ability to identify and address staff’s individual training needs.

The provider was in breach of regulations relating to staffing and fit and proper persons employed.

Following our assessment, the registered manager confirmed an approved provider had been sought to deliver restraint training to all staff and they had also changed to another new training provider to deliver all mandatory training.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.