CQC report explained · a nursing home
What the CQC found at Melton Place
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2024
Melton Place is rated Inadequate overall; inspectors found serious safety and leadership failures despite some kind care and good care planning.
Inspectors visited on 21 and 22 November 2023. They spoke with patients, relatives and staff, inspected both wards, reviewed care records and observation records, checked medicines, and examined policies and staffing information.
The overall rating fell from Requires Improvement to Inadequate. Safe and Well-led were rated Inadequate. Effective, Caring and Responsive were rated Requires Improvement. Inspectors found serious concerns about long-term segregation, medicines, agency staff training and access to patient records.
There were also positive findings. Care plans were described as personal and focused on recovery. Staff involved patients and families in decisions where possible. Inspectors saw some kind interactions and found regular supervision, appraisals and team meetings.
Personal care plans
Inspectors found that care plans covered patients’ physical and mental health needs and were personal and focused on recovery.
“Staff developed a comprehensive care plan for each patient to meet their mental and physical health needs.” from the report
Family involvement
Patients, families and carers were involved in care decisions when possible, and families were generally kept updated when consent allowed.
“Staff actively involved patients, families and carers in care decisions when it was possible to do so, and appropriate consent had been sought.” from the report
Staff support
Managers gave substantive staff regular supervision and annual appraisals. Team meetings were held weekly and recorded.
“Managers supported all substantive staff with regular, clinical supervision and annual constructive appraisals of their work.” from the report
Incident learning
Staff reported incidents, investigated them and shared learning through safety meetings, supervision and team meetings.
“Managers investigated incidents and shared lessons learned with the whole team and the wider service.” from the report
Communication aids
Inspectors saw easy-read documents and different communication methods, including pictorial aids, electronic devices and whiteboards.
“We saw numerous easy read documents on the wards.” from the report
Long-term segregation
seriousA patient had not been able to mix freely with other patients for five months. Staff did not recognise this as long-term segregation, so required reviews, safeguards and a reintegration plan were not in place.
“Staff had failed to follow best practice, including guidance in the Mental Health Act Code of Practice when a patient was nursed in long-term segregation.” from the report
Unsafe medicines processes
seriousThere was no pharmacist guidance for crushing covert medicines, and PEG medicines did not have detailed administration plans. A patient was also given expired eye ointment.
“There was no available guidance from the pharmacist on how these medicines should be crushed for safe administration.” from the report
Agency staffing and training
seriousThe home used a high volume of agency staff. Inspectors could not confirm that all agency staff had completed induction or training in reducing restrictive interventions, and agency healthcare assistants could not access electronic patient records.
“The service used a high volume of agency healthcare staff to keep people safe from avoidable harm.” from the report
Limited psychology support
needs fixingThere had been no regular psychology staff for at least 12 months. Some care plans included psychological interventions that patients had not received.
“Psychological therapies were not routinely offered due to no psychology staff in post” from the report
Care tasks and feedback not consistent
needs fixingStaff did not always record required mouthcare or PEG site care. Feedback from community meetings was not consistently followed up or reported back to patients.
“Staff failed to consistently record actions taken following feedback from community meetings.” from the report
- 01What has been done to ensure any long-term segregation follows the Mental Health Act Code of Practice, including regular reviews and a reintegration plan?
- 02How are covert and PEG medicines now assessed, planned and administered safely?
- 03How do you check that every agency worker has completed induction and restrictive intervention training before working with patients?
- 04Can agency healthcare assistants now access electronic patient records directly, and how is important information checked between shifts?
- 05How have you restored regular psychology support and ensured that psychological interventions in care plans are delivered?
This was a comprehensive inspection covering all five key questions, but the supplied service name and the report heading do not match. This explanation was written from the published report of 25 March 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, March 2022
Melton Place rated Requires Improvement; inspectors found clear progress but ongoing concerns about medicines, staffing, care and patient involvement.
This was a follow-up comprehensive inspection on 7-8 December 2021. Inspectors visited all three wards, reviewed care plans, risk assessments and prescription charts, and spoke with patients, families, carers and staff.
The home had improved since the previous inspection. The wards were generally safer and cleaner, staffing levels were enough for safe care, records were stored securely, and staff worked well in specialist teams. Restrictive practices had also reduced.
However, inspectors found important gaps. Medicines were not always stored or given safely. There were many staff vacancies and heavy use of bank and agency staff. Some care plans were not followed, patient meetings were irregular, and some families did not receive good support or information.
All five areas were rated Requires Improvement. This means the home was not consistently meeting the expected standard, although inspectors found that it had improved and was taking action.
Improved safety and cleanliness
The wards had become safer and cleaner since the previous inspection. Staff followed infection control procedures more consistently and managers acted quickly when problems were identified.
“The service had made significant progress since our last inspection.” from the report
Enough clinical cover
Inspectors found enough nursing and medical staff on the shifts reviewed to keep patients safe, although the home relied heavily on temporary staff.
“We reviewed duty rota’s over a three week period and found that the service had enough nursing and medical staff to keep patients safe” from the report
Specialist rehabilitation
Patients had access to a range of specialist staff and treatments suited to their rehabilitation needs. Care plans were generally personalised and recovery-focused.
“We saw comprehensive personalise, holistic, rehabilitation focussed care plans.” from the report
Reduced restrictive practices
The home had reduced the use of restraint and had a programme focused on least restrictive care and patient choice.
“Levels of restrictive interventions were low.” from the report
Better incident learning
Managers introduced regular meetings to review incidents, identify themes and share lessons with staff. Inspectors found evidence that changes had been made as a result.
“There was evidence that changes had been made as a result of feedback.” from the report
Planned discharges
Discharges were planned with other services and families or representatives. Inspectors found no delayed discharges in the previous year.
“The service had no delayed discharges in the past year.” from the report
Medicines safety
seriousMedicines were not always stored or administered safely. Inspectors found medicines handled on the floor, incomplete transfer records, unsecured medicine and administration without the required qualified nurse oversight.
“The provider must ensure the safe management of medicines including administration and storage are maintained on Cleves and Warwick wards.” from the report
Staff vacancies and temporary staff
needs fixingThe home had a 22% vacancy rate, 30 healthcare assistant vacancies and high staff turnover. It relied heavily on bank and agency staff to cover shifts.
“The provider had staff vacancies with high use of bank and agency staff to cover.” from the report
Care plans not always followed
seriousOne patient was left in the same wheelchair position for longer than their care plan allowed. Another patient's physiotherapy was not delivered during the week reviewed.
“Staff did not always follow individual person-centred care plans.” from the report
Patient and family involvement
needs fixingCommunity meetings were not held regularly and minutes often did not show what staff had done in response to feedback. Some families also reported poor communication and difficulty getting responses.
“Patients views not acted on.” from the report
Respectful communication
needs fixingMost interactions were kind and respectful, but inspectors heard one staff member speak to a patient in an insensitive and disrespectful way.
“However, we saw one incident where staff did not speak with sensitivity and respect to one patient on Cleves ward.” from the report
Some areas needed maintenance
minorInspectors found dirty non-patient areas and some maintenance hazards, including a sloping ensuite floor and sharp added door handles. Managers took immediate action during or after the inspection.
“Managers had addressed the concerns we had found at the last inspection and all patient areas were clean.” from the report
- 01What has changed to make sure medicines are stored, transferred and administered safely on Cleves and Warwick wards?
- 02How many permanent staff are now in post, and what is the current use of bank and agency staff?
- 03How do you check that each patient's care plan is followed, including repositioning and physiotherapy instructions?
- 04How often are community meetings now held, and how do you record and act on patient feedback?
- 05How will families receive regular information and get a response when they raise concerns?
This was a comprehensive follow-up inspection of the long-stay and rehabilitation mental health wards, checking three previous warning notices and reviewing all five CQC questions. This explanation was written from the published report of 18 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Melton Place
6 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- March 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2022Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2021Inadequatedown from Requires improvementSafe: InadequateEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inadequate
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2014
Registered with the Care Quality Commission on 8 December 2014.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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