Archived: Melbourne Home

Updated 7 October 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Melbourne Home 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.

The service did not have a manager registered with the Care Quality Commission (CQC). This meant the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced. We returned announced on the second day to complete the inspection.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with and spent time with nine people who use the service. We spoke with three volunteers, two care staff, the interim manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included two people’s care records and three medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and an audit completed by the interim manager.

Updated 7 October 2021

About the service

Melbourne Home is a care home providing personal care for up to 17 people aged 65 and over. At the time of the inspection there were 15 people in residence.

People’s experience of using this service and what we found

People were at risk of not receiving their medication as prescribed. Systems to monitor the safe use of medicines were not in place. Staff’s knowledge and competence for the management of medicines could not be evidenced. The interim manager had enrolled staff on a training course.

Potential risks were assessed; however, improvements were needed to the review process in determining the level of risk so that any changes to people’s needs could be identified and implemented. The provider’s policy for the recruitment of staff, and the use of volunteers were not followed, which meant people were supported by people who had not had their suitability to work with them consistently checked, putting people at potential risk.

An interim manager appointed in July 2021 managed the day to day running of the service . The nominated individual regularly visited, speaking with people and staff which included the interim manager. However, they told us they were not involved in the monitoring of the service to ensure good outcomes for people.

Systems and processes for the governance of the service were ineffective. Information as to the quality of the service, its performance, and areas for improvement were not shared with the Board of Trustees. This had restricted the service’s ability to continually learn and improve.

Some of the provider’s policies and procedures had not been implemented, which meant unsafe practices had developed, placing people at potential risk. Systems and processes to provide accessible information and records were not in place.

Systems were in place for regular cleaning of the service to prevent and control infection. Visitors to the service were required to evidence a negative COVID-19 test and were required to wear personal protective equipment (PPE). Staff were seen to be wearing PPE appropriately. People and staff were routinely tested for COVID-19, consistent with government guidance.

People were supported to receive person centred care with regards to their beliefs and preferences. People spoke of their enjoyment of religious services held at Melbourne Home, and opportunities to pray. People were able to engage in activities and events which they enjoyed, which include trips out and activities within the service. People were positive about the caring and supportive approach of staff, and we saw people, staff and volunteers took comfort and enjoyment through laughter and conversation.

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

Rating at last inspection

The last rating for this service was Good (published 11 October 2018).

Why we inspected

We received concerns in relation to staffing, the safe care of people and the day to day management of the service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.

Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Melbourne Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to leadership and governance, medication management and staff recruitment.

Please see the action we have told the provider to take at the end 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.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.