Melville House

⚠ The provider failed to assess and mitigate against risks to people, including risks from the behaviour of others, accident and injury, and dietary needs. They also failed to use incidents to learn lessons to minimise future risks.

⚠ Medicines management systems were not always safe. People were not always administered their medicines as prescribed, monitoring systems were not robust, topical creams were not applied at the required frequency, 'as required' sedating medicines were administered regularly without documented reason, and medicine storage temperatures exceeded recommended maximums without action.

⚠ People were not always supported to access healthcare professionals in a prompt and proactive way, leading to delays in referrals for weight loss and mental health conditions. Where people's capacity impaired their ability to make safe choices, appropriate healthcare intervention was not always in place, such as for dental hygiene.

⚠ Staff had inadequate knowledge of the MCA, how to assess capacity, or make best interests decisions. Decisions were made on behalf of people lacking capacity without following MCA principles, including for the use of equipment, changes to diet, and the administration of medicines. Staff were unaware of specific conditions outlined …

⚠ The provider failed to ensure people's dignity was upheld, with incidents of people in communal areas without clothes and staff not taking proactive steps. People's personal hygiene and appearance were neglected, with irregular baths/showers. Staff were seen laughing when someone came to them confused and failed to take consistent proactive …

⚠ Care plans did not contain detailed information about people's individual preferences, including personal care needs, leisure, and religious needs. Staff were unaware of specific information in care plans, such as optical prescriptions. People reported insufficient activities and leisure opportunities. This was a continuing breach.

⚠ End of life care plans lacked information about people's personal preferences and wishes. Considerations for dignity, such as for a person approaching the end of life residing in a shared room, had not been discussed or considered. This formed part of a continuing breach.

⚠ The provider failed to address concerns from prior inspections, ensure the management team understood required standards, or ensure quality assurance systems effectively identified risks and areas for improvement (e.g., medication, record keeping, weight loss, risk management, challenging behaviour, falls, staff deployment, staff competency, dignity). Communication systems were ineffective, and there …

⚠ The provider failed to submit statutory notifications to CQC as required by law, including for safeguarding concerns and incidents involving the police.