We inspected Melrose on 11 April 2018 and the inspection was unannounced. We previously carried out a comprehensive inspection of the service on 24 April 2017. We found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because we identified concerns in relation to the management of medicines which the provider had not identified and the service received an overall rating of ‘requires improvement’. After that inspection, the provider wrote to us to describe what action they would take to meet the legal requirements.

We undertook this inspection to look at all aspects of the service provision, check that the provider had followed their action plan, and confirm that the service now met legal requirements. We found during this inspection that improvements had been made and the breach relating to safe management of medications had been met. However, we identified further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for Melrose remains as requires improvement. We will review the overall rating of requires improvement at the next comprehensive inspection, where we will look at all aspects of the service and to ensure the improvements have been made and sustained.

Melrose is a ‘care home’ which is registered to provide accommodation for up to 29 adults who require support with personal care and specialises in providing support for younger adults with enduring mental health conditions. 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. At the time of this inspection there were 28 people living at the service on a permanent basis and one person who was leaving the service that day after a short ‘respite’ stay.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection, we identified breaches of regulations. This was because the systems and processes to monitor the quality and safety of the service were not sufficiently robust to identify shortfalls in records and areas that needed improvement. Staff recruitment and appraisals records were disorganised and contained gaps and people’s daily records had not been checked . Some staff practices were task led and not person centred. At lunch time staff did not instigate any conversation with people and some interactions that did take place were not dignified or respectful.

Some of the communal areas of the service were not homely. We have made recommendations for the provider to seek advice from a reputable source with regards to current best practice for creating a homely environment.

People were involved in the assessment of their needs and plans were in place for how they wanted and needed their support to be delivered. People were free to come and go throughout the day and spend their time as they wished.

People told us they felt safe and well cared for living at Melrose. They told us staff were always available to support them if needed and that they felt able to raise concerns with them. Staff new people well and most of the time were caring and respectful in their interactions with individuals.

Robust systems were in place to ensure the safe handling of medicines. People were supported to take responsibility for their own medicines whenever possible. The service was clean and the premises and equipment were routinely checked and serviced.

Where necessary, people were supported to access advocacy services to help them express their views

This inspection was carried out on 24 and 27 April 2017 and was unannounced. Melrose is an ex local authority home built over two floors. It is in an area of Hoylake that is close to transport links and shops. The home is registered to accommodate up to 29 people and at the time of our inspection there were 27 people were living at the home.

The service required a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of inspection the service had a manager in post who had been registered with Care Quality Commission since March 2011. The service also had a care manager and administrative staff in post.

During our inspection, we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to the management of medicines.

Medication was not safely managed due to lack of accuracy and completeness of recording. There were gaps on the medication administration record (MAR) sheet and liquid medications had not been dated when they had been opened, this meant that there was a possible risk of people being given out of date medication. We identified that some staff who were responsible for the administration of medications needed additional training, this was immediately rectified by the management in the home.

We identified that staff did not always follow a person’s risk assessment surrounding access to drinks. This was brought to the attention of the management and they immediately acted on the information.

Some training was still required for some staff in mental health topics as the home offered a specific mental health residential service and staff safeguarding knowledge needed updating. We discussed this with the management of the home who immediately organised additional training for staff.

Staff were recruited safely and we saw evidence that staff had been supervised regularly.

Each person living in the home had a plan of care and risk assessments in place. These were specific to them and were regularly reviewed.

The Mental Capacity Act 2005 and the associated deprivation of liberties safeguards legislation had been adhered to in the home. The provider told us that some people at the home lacked capacity and that a number of Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority in relation to people’s care. We found that in applying for these safeguards, peoples’ legal right to consent to and be involved in any decision making had been respected.

We saw that infection control standards in the home were monitored and managed appropriately. The home was clean, safe and well maintained. We saw that the provider had an infection control policy in place to minimise the spread of infection

We saw that the people living in the home knew who the registered manager was. We noted that the care manager was a visible presence in and about the home.

The home had quality assurance processes in place including audits staff meetings, quality questionnaires and residents meetings. The home also had up to date policies in place that were updated regularly and staff were informed of the updates through staff meetings and emails.

This unannounced inspection took place on 13 January 2015. At our last inspection, on 16 January 2014 we had found there was a breach of Regulation 22 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, regarding staffing numbers and training. The provider sent us an action plan to tell us that this would be addressed by 01 June 2014. We found on this inspection that the breach had been dealt with.

The home required a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was registered to accommodation for 29 people and at the time of our inspection, there were 24 people resident, one of whom was there for short term respite. The people supported by the service all had mental health needs and some had additional physical needs.

The home was an ex local authority home, it was light, airy and was well laid out. There were peoples’ bedrooms throughout the home and most communal areas were on the ground floor. The home had a separate part of the top floor designed to enable people to live semi independently and for some to work towards being able to live independently in the community. This part had six bedrooms, with its own kitchen and lounge. People were able to take part in everyday tasks such as making drinks and snacks.

We found that most people felt safe and happy with the care and the staff. However, people were not given a choice about many of the aspects of their daily life such as when to have a snack. Staff were supported and trained but they were not conversant with the Mental Capacity Act (2005) or the associated Deprivation of Liberties Safeguards. The management style was not appropriate to the people being supported and the way the home was run did not allow people to live their lives freely or independently.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which correspond to regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and we also found a breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version the report.

We spoke to different people about this service to gain a balanced overview of what people experienced, what they thought and how they were cared for and supported. We spoke to two people resident at the service and three staff members. We spent time observing people using the service, to see how they were cared for and how staff interacted with them.

People said that they had no concerns about the home or the care that service users received, and that the staff were, “pleasant” and that the manager was approachable. A service user said that they would recommend the service to other people.

We saw that medicines were managed safely.

People told us that there was a high turnover of staff. We saw that there were adequate numbers of staff to support people using the service but that few staff had received appropriate training to care for people with mental health needs.

We saw that provider monitored some aspects of the quality of service provision and assessed safety risks regularly.

We spoke with three people who told us that they liked living in the home. They told us that they enjoyed the food and they got "plenty" to eat.

Two of the people we spoke with told us that they could make a complaint if they wanted to. One person said that they had nothing to complain about.

We carried out an unannounced, comprehensive inspection of this service on 13 January 2015. Breaches of legal requirements were found. After the inspection the provider wrote to us to say what they would do to meet legal requirements in relation to consent to care and treatment, meeting nutritional needs and submitting statutory notifications.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Melrose on our website at www.cqc.org.uk

This report covers our findings in relation to those requirements. In addition, during the inspection on 07 and 10 September 2015, we found that there were concerns relating to medication and staffing which we have included in this report.

The home required a registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Melrose had a registered manager who had been in post for several years.

At the last inspection on 13 January 2015, we asked the provider to take action to make improvements relating to consent, nutrition and hydration, and statutory notification submissions. The provider had provided us with an action plan which stated that they would achieve these requirements by 31 May 2015. We found that they had met the requirement regarding nutrition and hydration but had not met the requirements relating to consent and statutory notification submissions to the Care Quality Commission (CQC). The provider had not improved the training and understanding of the Mental Capacity Act and had not completed the necessary capacity assessments. The provider had not submitted the required statutory notifications to CQC as required as we knew there had been concerns raised by other organisations to CQC.

During the course of this inspection we found that there had been a serious medication error which had gone unnoticed. We had also been notified by whistle-blowers that there were not enough staff throughout the course of each day and night. The provider had sent us a copy of the staff rota which showed that there should be at least five staff members on duty throughout the day. However we found that this was not people's experience. We also found on the days of our inspection that there were insufficient staff on duty.

We have made a recommendation in relation to the staffing levels.

We found breaches of the Health and Social Care Act 2008, relating to consent, statutory notifications and medication administration. You can see what action we have told the provider to take at the back of the full version of this report.