18 October 2022
During an inspection looking at part of the service
Memory House is a residential care home providing accommodation and personal care to up to 39 people. The service provides support to people living with dementia. At the time of our inspection there were 34 people using the service. The care home accommodates people in one adapted building.
People’s experience of using this service and what we found
Management did not have adequate oversight of the service and systems in place to monitor the quality and safety of the service were not operated effectively. There was a lack of recognition and understanding of risk with a lack of robust assessments and controls in place to protect people and keep them safe. The provider’s systems did not identify where things were going wrong.
There were no clear management systems followed in practice, monitored and reviewed that enabled effective recruitment, maintenance and retention of staffing levels. Recruitment practices were not robust because checks were not always complete. Whilst the staff, at the time of our inspection, showed commitment and compassion towards people they were supporting, there were not enough of them to keep people safe and meet their needs effectively. There was a high incidence of unwitnessed falls and staff were not able to spend meaningful time with people.
New and inexperienced staff members were not sufficiently supported to deliver safe and appropriate care. Learning and development was not managed and planned in a way that ensured staff had the opportunity to build on their knowledge base and develop their skills to carry out their roles and meet people’s specific needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People had choice and access to enough food and drink throughout the day and night.
People received their medicines in a safe and supportive way and were supported to access healthcare services and support as and when they needed.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was good (Published 7 January 2022)
Why we inspected
This inspection was prompted by concerns received about falls, safeguarding incidents and staffing levels. A decision was made for us to inspect and examine those risks.
We undertook a focused inspection to review the key questions of Safe, Effective and Well-Led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to inadequate based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well-led sections of this full report.
Senior management acknowledged our findings and started to take action to mitigate risk and address our concerns during the inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Memory House on our website at www.cqc.org.uk.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.