Melton Place

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

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

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

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

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

A 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

There 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

The 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

There 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

Staff 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