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CQC report explained · a residential care home, run by Leicestershire County Council

Melton Short Breaks Service

21 Victor Avenue, Melton Mowbray, LE13 0GG

Requires improvementpublished 16 March 2024, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Requires improvement
There had been multiple medicine errors, including missed epilepsy medicine, and not all medicine checks or competency checks were completed. Risk records and care records were sometimes unclear, and inspectors found a restriction that negatively affected a person.
Effective?
Requires improvement
Some staff did not have up-to-date moving and handling or other training. Mental capacity records and best interest decisions were incomplete or conflicting, so staff did not always have clear guidance about consent and support.
Caring?
Good
People were treated with kindness, dignity and respect. Relatives gave positive feedback and said people were supported to be independent where appropriate.
Responsive?
Requires improvement
Care plans did not always record people's religious, sexuality and other personal needs well enough. Complaints and staff concerns were not always followed by effective action, although people had communication passports and a wide range of activities.
Well-led?
Requires improvement
Quality checks did not reliably identify or fix problems with medicines, care planning, risk management, training and mental capacity assessments. Staff described weak leadership, confidentiality concerns and a culture where they did not feel able to challenge poor practice.
The latest report, explained

What inspectors found, March 2024

Melton Short Breaks Service is Rated Requires Improvement; inspectors found kind care but serious problems with medicines, consent, training and leadership.

Inspectors visited on 15 and 17 November 2023. They reviewed five people's care records, medicines records, audits, complaints, accidents and recruitment files. They spoke with one person, three relatives, two health professionals and nine staff.

The home was caring and relatives said their loved ones were well cared for and enjoyed staying there. People had varied activities, accessible spaces, good food choices and support with communication. Visitors were welcomed.

However, medicines were not always managed safely and there had been several medicine errors. Records about risks, care needs and mental capacity were sometimes unclear or conflicting. Some staff training was out of date or missing. Inspectors also found weak leadership, poor oversight and concerns about safeguarding, consent and personalised care. The overall rating and the ratings for Safe, Effective, Responsive and Well-led were Requires Improvement. Caring was rated Good.

What inspectors praised
  • Kind and respectful care

    Inspectors found that people were treated with kindness, dignity and respect. Relatives spoke positively about the care and support.

    People were treated with kindness by staff who delivered care.from the report
  • Activities and relationships

    People were offered varied activities and trips, including opportunities linked to their social and cultural interests. There was also plenty to do inside the home.

    People experienced a wide and varied programme of opportunities in regard to how they chose to spend their time.from the report
  • Accessible environment

    The building had accessible bedrooms, wet rooms, communal areas, a sensory room and a garden. Inspectors found it exceptionally clean and tidy.

    The environment was exceptionally clean and tidy.from the report
  • Communication support

    Communication passports explained people's preferred ways of communicating. Easy-read staff profiles helped people know who might support them.

    People had communication passports in their files which explained how they preferred to communicate with staff and others staying at the service.from the report
  • Food and cooking

    People had food and drinks available and staff understood their dietary needs and preferences. People were encouraged to cook and bake to build confidence and skills.

    People were encouraged and supported to cook and bake during their stay.from the report
What inspectors were concerned about
  • Medicine safety

    serious

    There had been multiple medicine errors. Checks were not always completed properly, investigations missed important information, and some staff had gaps in their medicine competency records.

    Medicines were not always managed safely. Multiple medicine errors had occurred.from the report
  • Safeguarding and restrictions

    serious

    Inspectors found a restriction that negatively affected a person. Staff had not identified it before the inspection, despite having safeguarding training.

    People were not always protected from the risk of abuse and improper treatment.from the report
  • Staff training

    serious

    Some staff lacked evidence of moving and handling training, and other training was out of date. Planned supervised medicine sessions were not always completed.

    Staff did not always have sufficient training to be able to meet people's needs.from the report
  • Leadership and oversight

    serious

    Audits did not reliably find or address problems. Staff said they could not always challenge leaders, and some concerns were not dealt with correctly.

    The provider had failed to operate effective quality assurance systems to assess and monitor the safety and quality of people's care.from the report
  • Personalised care records

    needs fixing

    Records did not fully explain some people's religious needs or how they preferred to identify and be supported. This could make person-centred support more difficult.

    There were shortfalls in how people's needs were identified, particularly in respect of protected equality characteristics.from the report
Questions to ask them, based on this report
  1. 01What changes have been made to prevent further medicine errors, and how are staff's medicine skills checked now?
  2. 02How do you make sure every person has a clear mental capacity assessment and a recorded best interest decision where needed?
  3. 03Which staff are trained in moving and handling and in each person's specific care needs, and how do you track overdue training?
  4. 04How are safeguarding concerns and restrictive practices identified, reported and reviewed?
  5. 05What has changed in your audits and complaints process so that repeated concerns, such as missing personal belongings and inaccurate care records, are acted on?

This was a comprehensive inspection covering all five key questions, with visits on 15 and 17 November 2023 and inspection activity continuing until 24 November 2023. This explanation was written from the published report of 16 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 story over the years

Every inspection of Melton Short Breaks Service

4 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.

  1. March 2024Requires improvementcurrent ratingdown from Good
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read what inspectors found at Melton Short Breaks Service

  2. October 2018Goodup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. July 2017Requires improvementdown from Good
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  4. June 2015Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. October 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. January 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. December 2010

    Registered with the Care Quality Commission on 16 December 2010.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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