Archived: Melville House

People’s experience of using this service:

People were not sufficiently protected from the risk of harm; including potential abuse, the behaviour of others, health concerns or accidents and injury. The provider’s risk management systems were inadequate. People were not protected by safe medicines management systems.

People were not being supported by sufficient numbers of staff with the right skills that were being deployed effectively.

People’s rights were not upheld with the effective use of the Mental Capacity Act 2005. People’s needs were not being accurately assessed, understood and communicated. Care provided did not consistently meet people’s needs. People were not receiving care that was truly person-centred and met all of their needs; including religious needs and leisure.

People did not receive support that was consistently caring and respectful that upheld and promoted their dignity and independence.

People were not protected by robust quality assurance and governance systems. The provider failed to ensure the systems they had in place identified risk to people and areas of improvement needed. The provider failed to make sufficient improvements and as a result people were living in a deteriorating service and were exposed to the risk of harm.

Rating at last inspection: At the last inspection the service was rated ‘requires improvement’ (inspection completed 22 February 2019 and report published 01 May 2019). The service has been rated as requires improvement seven times prior to this inspection.

Why we inspected: We completed this inspection due to our previous inspection findings and ratings in addition to concerns that were received from the public and local authority. The inspection was brought forward due to information of concern regarding the quality of care being provided to people.

Enforcement: Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up: Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

At our previous six inspections we rated Melville house as requires improvement, this since April 2015. Despite enforcement action we had taken prior to this inspection the provider had not made sufficient improvements to improve the rating to ‘good’, and address breaches of the law that have been identified. Following the last inspection, we asked the provider to complete an action plan to show how, and by when, they would address breaches of law that we had identified at our last inspection. This action plan showed most of the actions identified would have been addressed by this latest inspection. We found breaches of regulation from the last inspection in respect of safe care and treatment and notifications to CQC had been addressed. People told us they felt safe and works had been completed to make the service safer. Additionally, there was improvement in the way risk to people was managed.

Care, on many occasions, was task focussed though, with little interaction between care interventions which meant people’s preferences were not always met. People did not always have an enjoyable meal time experience and we saw meal choices were limited. There were however a number of occasions where we saw people were supported by staff who we saw were caring and we saw some good relationships between people and staff.

The environment, despite attempts staff had made to improve this, did not always reflect the needs of people living with dementia.

People were supported by care staff who had received training in a range of skills and knowledge, although there were some areas where further updates were needed to improve staff knowledge and to embed recent learning especially in respect of dementia care. The manager confirmed further training for staff was planned. Staff felt supported in their role, although there was a lack of formal one to one support for staff. People's health was supported as staff worked with other health care providers to ensure their healthcare needs were met.

People's care plans reflected people’s needs and to some extent their preferences. However, staff were not always able to explain recent changes to people’s care. This was because they had not always seen the person’s care plan, although they did have access to summaries of people’s current needs.

People said they could complain to staff although staff did not always have a good knowledge of the provider’s complaints process. The manager could describe how complaints would be dealt with, although none had been received by the provider since our last inspection.

People were happy with the care they received but many told us they would like more stimulation and had little to keep them occupied, and people told us they were ‘bored’. People told us staff were approachable and they felt well treated but not all knew who the manager or seniors were. We saw people’s involvement in care planning had improved, but was still inconsistent.

There was some improvement in quality monitoring systems which included audits and observations of staff practice. This had helped the provider address and improve the safety of the service, although there was still scope to develop the quality of person centred care and build on and embed improvements that had been made, as well as drive improvements in other areas.

Rating at last inspection: The rating for the service at our last inspection was ‘requires improvement’ (Published on 03/01/2019).

Why we inspected: We inspected the service to checks improvements had been made after the last inspection when we identified breaches of regulations. These related to people’s safety, legally required notifications and governance.

Enforcement: We found the provider was still not compliant with regulations related to governance and we found an additional breach in respect of person centred care.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner. There is a condition on the providers registration to supply monthly reports as to the progress in making improvements to the service and these will be reviewed by us at the point they are received.

At our last inspection in March 2018, we found the provider to require improvement in all five key areas. We also found breaches in Regulations 12 and 17. Regulation 17 was breached with a Notice of Decision being served upon the provider to return monthly reports to us to demonstrate continued improvement. The reports have been returned to us as specified. However, at this inspection we did not find the required improvements had taken place and the breaches were not met.

Melville House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Melville House accommodates up to 29 people in one building. The building was not purpose built and is formed of two large houses being joined together with corridors. The home does not have 29 individual rooms and up to 8 people use shared bedrooms.

At the time of our inspection Melville House did not have a registered manager in place. A new manager had begun working at the home and had applied to become registered with us. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Melville House did not keep people safe. Not all people had up to date or accurate risk assessments. People were not always protected from the risk of cross infections and the environment of the home was not clean. Lessons were not learnt from accidents and incidents that had happened. Staff understood how to safeguard people and medicines were given safely.

People were not always supported effectively. People were not involved in the planning or review of their care and staff did not always demonstrate that they had the skills to deliver effective care. The design of the premises was not effective in delivering the best possible care and there was no signage for people to orientate themselves. People did not always consent to the care and treatment they received. People had enough to eat and drink and were supported to live healthier lives with good involvement of health professionals.

People said that staff were caring and kind, but we saw that people were not always treated with dignity. There was no approach at Melville House to promote people’s independence. People received their care in private, but were not actively involved in making decisions about their care.

Melville House did not always respond well to people’s needs. People were not involved in their care and may not have had their decisions about when to be resuscitated known about by staff and managers. People were not supported to maintain their interests or hobbies and had very few activities to take part in during the day. Melville House did not comply with the Accessible information standard which meant that people did not have information in a way that they could access easily.

Melville House was not well led. The provider had not improved the effectiveness of the auditing system as required by law. The provider had also failed to ensure that notifications were returned to us as required by law. The vision to make improvements and to meet standards was not clear.

We have made a recommendation improving the environment for people living with dementia.

At the last inspection on 22 and 28 March 2018, we asked the provider to take action to make improvements in relation to safety, notifying us of events and the quality assurance processes. At this inspection we found that insufficient progress had been made in these areas. The provider remains in breach of these areas. You can see what action we told the provider to take at the back of the full version of the report.

Melville House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Melville House accommodates up to 29 people providing residential and nursing services and a service for people living with dementia. At the time of our inspection 27 people were living at the home.

At the time of this inspection there had been no registered manager in post for a number of months as the former manager had not applied to become registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider was aware as part of their registration a registered manager was required to be in post. The provider had recruited to the post of manager however they had not commenced their employment at the time of this inspection.

At the previous inspection on the 27 April 2017 the provider had an overall rating of requires improvement. At this inspection the overall rating has remained at requires improvement .This is the fifth consecutive inspection where the rating has been requires improvement.

The provider's quality checking arrangements were not consistently strong and effective in identifying, making and sustaining improvements in the quality of care people received. Managerial changes together with the lapse in the provider’s checking procedures had led to inconsistency in leadership. This had impacted on aspects of the quality of care to support people in receiving safe, effective and responsive care which was well led.

There were inconsistencies in the provider's systems and staff practices to provide assurances that all risks to people were safely and effectively managed. Some risks to people's health and safety were not well managed which included monitoring people’s weight loss, administration of medicine and reducing risks of fire hazards.

Staff and the provider knew how to report allegations of abuse. However, we identified an occasion when the provider had not made sure an incident of abuse had been reported to the local authority or ourselves. Staff reported accidents and incidents however the management team did not review them to ensure appropriate action had been taken and to reduce the risk of incidents happening again.

Staff understood the principles of infection prevention and control. These principles were not always embedded in staff’s everyday practices to reduce the risk of cross infections and to support people to live in a pleasant home. The provider had an on-going refurbishment plan but there was more to do in supporting people to live in a pleasant home where facilities met their needs.

People’s care records did not consistently hold the information to guide staff practices to support people to receive individualised care. Staff did not always explore how they could support people to live the lives of their choosing. There were on-going improvements in order to offer people a broad range of things to do for fun and interest.

People were confident there were enough staff to meet their needs safely. Staff were available to respond to people who needed reassurance to improve their well-being.

Appropriate checks had been completed for new staff to ensure they were safe to support people who lived at the home with their care needs. The training provided for staff was not consistently embedded in staff practices and there was no regular oversight of where improvements were required to support staff to be as effective as they could be.

People were supported to see, when needed, health care professionals. Staff recognised changes to people's physical well-being and relatives said they were kept well informed by staff regarding their family member’s health and well-being. The management and oversight of people’s medicines required improvement. People were supported with their meals, where needed, Some people believed they would benefit from more areas to eat their meals and dining tables to enhance their pleasure at meal times.

We saw that staff obtained people's consent before providing care to them. Where people could not consent, assessments to ensure decisions were made in people's best interest had been completed. Staff had variable knowledge about where people had authorisations in place to ensure people had the care and support they required and any restrictions were lawful.

Staff were caring however we saw some practices were focussed on tasks rather than providing individualised care. When staff did communicate with people we saw examples of kind care, with staff showing affection and compassion towards people. People were supported to maintain relationships which were important to them.

We found three breaches of the Health and Social Care Act (2008) Regulated Activities 2014 Regulations. You can see what action we asked the provider to take at the back of the full version of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

After the inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches. The provider took action and at this inspection we found improvements had been made.

Melville House is registered to provide nursing care and support for up to 29 older people who have needs relating to their age or dementia. On the day of our inspection there were 26 people living at the home.

Melville House has been without a Registered Manager for over six months. The current acting manager was present during our inspection and told us that they were applying to CQC to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People and relatives told us that they had no concerns about safety at the home. People were supported by staff who had received training on how to protect people from abuse. Risk assessments had been completed to minimise the risk to people. There were appropriate recruitment processes in place. Medicines were given to people as prescribed and were managed safely.

People were supported by staff who received training to enhance their skills and knowledge, and we noted that this was being further developed. We found that people may have benefitted from more staff being available to support them. People enjoyed their meals told us they were supported to express their opinions about the meal choices. Staff were knowledgeable about how to support people to maintain good health and accessed professional healthcare support for them when necessary.

People told us and we observed that staff were kind and compassionate in the way they supported and cared for people. People were given support to make their own decisions about their day to day care and support needs. We saw that that staff respected people’s privacy and dignity.

Staff were knowledgeable about people’s personal preferences and what was important to them. However very few activities were on offer for people to enjoy, and the environment of the home would benefit from being more dementia friendly. There was a complaints procedure in place.

The manager was well liked by people, their relatives and staff who all felt that he could be approached and would respond well. The manager was using a variety of systems and audits to ensure continued improvements within the service and this process was being further developed as some people and their relatives were not as involved in their care as they could have been.

We carried out an unannounced comprehensive inspection of this service on 19 April 2016. At that time we identified breaches of three legal requirements. This was because people had not been supported to take their medicines safely and people were not always supported in line with the Mental Capacity Act (2005). The third breach related to Good Governance whereby the provider had not ensured that adequate systems were in place to monitor the safety and quality of care that people received.

After the last inspection, we met with the provider to discuss our concerns about the service. They also wrote to us to say what they would do to meet the legal requirements and to consistently provide a well led service.

We carried out this unannounced focussed inspection on 11 October 2016. We undertook the inspection to check if the provider had followed their plans and to confirm that they were now meeting legal requirements. At this inspection we found that although some improvements had been made to the support people received to take their medicines. Further improvements in terms of medicines management were still needed to ensure that compliance with the regulations would be maintained.

People could not be assured that their rights were upheld by the provider or that the service was being managed in a way that led to improvements in the quality of care people received. We found that sufficient improvements had not been made in relation to MCA and Good Governance and the home remains in breach of these regulations.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Melville House Care Home on our website at www.cqc.org.uk

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People using this service told us they felt safe and staff said they understood their roles and responsibilities to protect people. In some areas the service did not keep people safe from harm. People’s support and health needs were at risk of not being met because care plans were not always accurate or up to date. Some care plans did not reflect peoples changing needs. People did not always get their medicines safely and equipment within the home was sometimes not used correctly.

Staff did not consistently seek people’s consent before providing any care and support. Staff had a limited understanding of their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). We could not be sure that people were involved in decisions about their care or that their rights were being protected.

Recruitment checks were in place to ensure staff that were employed were safe to work with people. We found that staff were trained to support people effectively. Staff told us that they received regular supervision and that senior staff were always available for them to seek advice and guidance.

People spoke to us about how genuinely caring and kind staff were towards them. During our inspection however we saw that not all interactions with staff were caring and that some were very task focussed. People had access to enough food and drink, although the range of food provided was not varied. People were supported when necessary to access a range of health care professionals.

Staff and relatives knew how to raise complaints. Where complaints had been raised the registered manager had taken prompt and appropriate action. Staff spoke highly of the management and leadership they received.

The providers systems to monitor the quality and safety of the home were not robust and failed to ensure that issues were consistently identified and acted on to drive improvements.

You can see what actions we told the provider to take at the back of the full version of the report.

In January 2014 we inspected the home and at that time found that the home was non-compliant with some of the essential regulations. We issued warning notices against two regulations and compliance actions against three regulations. We conducted this inspection to follow up on the issues of concern and see what progress had been made. Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with 10 people using the service, 3 people's relatives, 5 of the staff supporting people living at the home and looking at records.

Shortly after the inspection we also met with the provider, their area manager and the home manager to discuss the issues and action that had been taken. We were told of further improvement actions that had been taken between the inspection and the meeting as well as other actions that were planned. The provider confirmed that they would not admit any more people into the home without the agreement of CQC until it was confirmed that compliance with the regulations had been achieved.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff we spoke with understood their role in safeguarding the people they supported and they had access to the homes own safeguarding procedure. However during our visit we identified an event that should have been considered as safeguarding that had not been reported or discussed with the local authority. We found that people were at risk from some parts of the premises that were not safe and hygienic. We could not find records to show that all equipment had been maintained and serviced as the manufacturer or trained technician required.

There was a policy to guide staff on their responsibilities under the Mental Capacity Act (MCA). Nurses had received training in this area and carers had been booked to attend training in July 2014.

We looked at the recruitment records of staff. Staff recruitment records did not show that all required recruitment checks had been undertaken, or that checks to ensure staff remained suited to work with vulnerable people were repeated routinely. This put people at risk of being supported by staff without the appropriate skills.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to safeguarding people, providing safe premises and staffing checks.

Is the service effective?

People's health and care needs had not all been assessed and risks related to people's health had not all been identified or planned for. Specialist dietary needs had been assessed but the dietician guidelines had not been followed. Some of the care plans had not been reviewed regularly and lacked details of how people's needs had changed. The care plans were therefore not able to support staff to meet people's needs in a consistent way.

There were not enough staff to support people to get up, eat their breakfast and undertake activities. We observed people still being supported up from bed after 12pm. One person we spoke with was happy with this, another person said, "Just get me out of my room. That would be nice. That is all I ask." Other people were unable to comment about the time they were supported up from bed, but we saw they had not been able to have their breakfast or a drink at a reasonable time. This did not show the service was effectively meeting people's needs.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing people's needs, planning their care and ensuring there are enough staff available.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, "I have nothing but praise for the place. My relative is really happy here." Other people told us staff were caring but they were concerned they may not have the skills needed to provide support for the people currently living at Melville House.

Is the service responsive?

During this inspection we identified a number of issues about which the provider took immediate action to rectify or improve the situation

Professional advice had been sought for some people when their needs had changed. However we did not find that staff had always followed the advice given. An example of this was eating and drinking guidelines for people who had difficulty swallowing and dietary guidelines for people at nutritional risk.

We have asked the provider to tell us what improvements that will make in relation to this area.

Is the service well-led?

People we spoke with praised the enthusiasm and efforts of the managers recruited in recent years but expressed disappointment that they had not stayed long, or achieved sustainable changes. We met the new manager during the inspection who demonstrated an ability to take immediate action to address issues of concern. The provider responded promptly to issues that were raised and took action to address the concerns identified. CQC had placed a condition of registration on the service. This required them to have a registered manager in post. This had been unmet for some time prior to the inspection. There was no evidence that the management of the home prior to the inspection had been effective or safe. Following the inspection we were advised that the new manager had commenced her application to become registered with CQC. We were told of increased monitoring actions that had been taken to check on the quality of the care provided.

People experienced care that was inconsistent and failed to fully meet their needs. We identified that shifts were not well led by the registered nurse, and that the staff team lacked direction and supervision on a shift to shift basis. This led to a chaotic style of care with staff repeating each others duties and some areas of the home being left without staff cover. We have asked the provider what they will do to meet the requirements of the law regards providing a well led service.

You can see our judgements on the front page of this report.

We found that people had not been supported with their health or personal care needs to a good standard. People appeared dishevelled and men we met had not been supported to shave.

On 02 January 2014 people told us they were hungry and thirsty. Comments made included; "I am very well, I just need some food" and one person said" When are we having something to eat? I am really hungry. No one has given us a drink."

We found that the running of the home was not adequately protecting people from the risk of abuse, neglect or acts of omission.

We found that some areas of the home were in a poor state of repair,this meant that some people were not being provided with a comfortable, homely or safe place to live.

The number of staff on duty was inadequate to meet the needs of the people accommodated. Staff had not been supported to access training to care for people safely or to gain knowledge about their specific needs.Staff did demonstrate compassion for the people they were supporting and comments included;"Staff are good."

The systems in place to ensure the service was well run and meeting the meeting needs of people accommodated were ineffective. The home did not have a registered manager and interim arrangements had not been adequate.

A relative that we spoke to expressed confidence that their spouse's care was planned, managed and delivered in the way that was promised. They told us that they were given a choice about when they wanted to get up and they thought the staff caring for them had a good manner and respected their dignity.

We found that care workers were skilled, qualified and competent but there were insufficient care workers on duty to help people to get up and get ready for the day at a reasonable time. Staffing levels at the service were not planned on the basis of an analysis of people's needs and risk assessment.