Dementia Matters

Updated 6 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Dementia Matters is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

A registered manager was in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We also contacted Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

We spoke with 1 person who used the service. Most people who used the service were unable to speak with us due to the nature of their condition. Therefore, we carried out observations of care to help us understand people’s experience. We also spoke with 12 relatives about their experience of the care provided. We received feedback from 16 members of staff including the registered manager, head of care, residential manager, a trustee, care staff, administrator and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records, this included elements of care records for 11 people including medicines records. We looked at the recruitment records for 3 staff and a variety of records relating to the management of the service, including policies and procedures. Following the inspection site visits we requested additional information by email and continued to seek clarification from the provider to validate the evidence we found.

Updated 6 December 2023

About the service

Dementia Matters is a care home providing accommodation and personal care for up to 10 people living with a mental health condition, learning disabilities and/or autism in one building. At the time of inspection there were 9 people living at the service. In addition to this care home, the service also provides a domiciliary care service to older people living in their own homes.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. At the time of our inspection 12 people received the regulated activity of personal care in their own home.

People’s experience of using this service and what we found

Care Home

Not all areas of the home were well maintained or clean and there were outstanding actions on the Legionella risk assessment. We also identified shortfalls relating to the maintenance of fire safety records. An effective safeguarding system was not fully in place. Prior to our inspection, a safeguarding allegation had not been referred to the correct agencies to ensure the appropriate action was taken. Records did not always demonstrate safe recruitment procedures had been followed. Medicines were not managed safely. An effective system was not fully in place to ensure there were sufficient staff deployed to meet people’s needs and ensure the cleanliness of the home.

Records did not show how people’s needs were assessed before they came to live at the home to ensure their needs could be met. Care records did not always show whether essential care tasks such as oral care had been carried out. An effective system to ensure staff were trained and supported was not fully in place. Records to evidence new staff had completed induction training were not always available. There were gaps in the provision of training including food hygiene. The design and décor of the home did not fully support people’s dignity, orientation or wellbeing. Not all areas of the home were well maintained. Records did not fully demonstrate how staff were following the principles of the MCA.

Relatives spoke positively about the caring nature of staff. One relative told us, “Staff are friendly and caring and have a good sense of humour and are very attentive. The atmosphere is warm and welcoming with helpful admin staff.”

Care plans did not always reflect people’s needs. In addition, an effective system to review people’s care and support needs was not fully in place. Records did not fully demonstrate how people’s social and emotional needs were met. Several relatives told us they had raised a complaint/concern. Records relating to concerns and actions taken were not available.

An effective system to monitor the quality and safety of the service was still not fully in place. We identified shortfalls across many areas of the service which had not been identified by the providers quality monitoring system.

Domiciliary Care Service

An effective recruitment system was not fully in place. Records did not always demonstrate that safe recruitment procedures had been followed. Medicines were not managed safely. We identified shortfalls with medicines records. Risks were assessed and monitored. One relative raised concerns about infection control which we passed to management staff. Safeguarding systems were followed by staff. One relative said, “Never any sign of abuse, I can hear them with him, very chatty and friendly.” There were enough staff deployed to meet people’s needs. Relatives told us there were sufficient staff and the same staff provided care and support.

Relatives spoke positively about the caring nature of staff. One relative told us, “The quality of care and the staff are wonderful, there’s not one of them who has not been considerate.”

An effective system to ensure staff were trained and supported was not fully in place. There were gaps in the provision of training. Staff appraisal, supervision and competency checks had not been carried out as planned to ensure staff were supported in their job role. Information relating to consent was recorded in people’s care plans.

People’s needs were assessed. Most relatives told us that care and support was delivered in line with people’s needs and choices. Records did not always evidence the number of complaints received and actions taken.

An effective system to monitor the quality and safety of the service was still not fully in place. We identified shortfalls which had not been identified by the providers quality monitoring system.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection

The last rating for this service was requires improvement (published 9 May 2023). There were breaches of the regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

This is the second time the service has been rated requires improvement.

Why we inspected

We carried out an unannounced focused inspection of this service in December 2022 and January 2023. Breaches of legal requirements were found in relation to safe care and treatment, good governance and duty of candour. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this inspection to check they had followed their action plan and to confirm they now met legal requirements. Prior to this inspection, we also received concerns in relation to the management of medicines and safeguarding allegations.

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.

We have found evidence that the provider needs to make improvements. Please see the full report below.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dementia Matters on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified 9 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during this inspection. These related to safe care and treatment, safeguarding people from abuse and improper treatment, premises and equipment, person-centred care, dignity and respect, recruitment, staffing, duty of candour and good governance.

Please see the action we have told the provider to take at the end of this report.

We are also following up outside of the inspection process the provider’s failure to ensure all notifiable incidents were reported to CQC. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan and meet with management staff and the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.