CQC report explained · a nursing home
What the CQC found at Redholme Memory Care Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risk assessments, medicines guidance and checks of accidents and incidents were not always complete or effective. Staffing, safeguarding, infection control systems and arrangements under the Mental Capacity Act were otherwise found to be in place.
- Effective?
- Good
- This question was not rated during this inspection.
- Caring?
- Good
- This question was not rated during this inspection. Inspectors did observe caring and patient interactions, and people and families spoke positively about the care.
- Responsive?
- Good
- This question was not rated during this inspection.
- Well-led?
- Requires improvement
- Audits and daily checks had not identified several of the problems found by inspectors. Some responsibilities had been delegated without being fully understood, and some required notifications had not been sent to the CQC.
What inspectors found, May 2023
Redholme Memory Care Limited was rated Requires Improvement; inspectors found kind care and enough staff, but weaknesses in safety checks and management oversight.
This was an unannounced inspection over three visits in March 2023. Two inspectors spoke with people living in the home, family members and staff. They observed care and checked care plans, medicines records, recruitment files and management records.
People were generally positive about the care. Staff knew people well, treated them patiently and there were enough staff on duty. The home was visibly clean, although some areas and bathrooms needed refurbishment. Some risk assessments and medicines records needed correcting.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement, changing from Good at the previous inspection. The main concern was that audits and daily checks had not reliably found or dealt with risks. The report identified a breach of Regulation 17 on good governance.
Kind, patient care
Inspectors saw staff take time with people and found positive relationships. People and families said staff were caring and knew people well.
“Support to people was delivered in a caring and patient manner.” from the report
Enough staff
Inspectors found enough staff on duty to meet people's needs. Staff were attentive and available during the inspection.
“There were enough staff on duty to meet people's needs.” from the report
Safeguarding arrangements
The home had systems for reporting suspected abuse, and inspectors were assured that safeguarding referrals and investigations had been completed appropriately.
“We were assured referrals had been made to the local authority safeguarding team when abuse had been suspected and appropriate investigations had been completed.” from the report
Clean areas and infection controls
Although some parts of the home needed refurbishment, the home was visibly clean and other infection control arrangements were considered appropriate.
“Other systems to prevent and control infection were appropriate.” from the report
Weak quality checks
seriousAudits and daily checks did not identify problems with risk assessments, recruitment records, medicines records or accident analysis. This was the main governance concern and was linked to a legal breach.
“Systems were either not in place or robust enough to assess, monitor and improve the quality and safety of the service or mitigate the risks relating to the health, safety and welfare of people.” from the report
Risk assessments
needs fixingA small number of risk assessments were incomplete or out of date when inspectors first checked them. The provider corrected them during the inspection, and inspectors found no evidence of harm.
“a small number of risk assessments needed to be updated or completed.” from the report
Medicines records
needs fixingSome records for medicines given only when needed did not contain all the expected information. This was addressed during the inspection.
“In a small number of records, we identified some shortfalls in the records relating to prescribed medicines administered on an 'as required' basis.” from the report
Refurbishment needed
needs fixingSome areas looked tired and bathrooms needed improvement to maintain safe and hygienic standards. Refurbishment work had started during the inspection.
“Areas of the service needed refurbishment to ensure safe and hygienic standards were maintained.” from the report
- 01What changes have you made to audits and daily checks since the inspection, and how do you know they are now finding problems?
- 02How are risk assessments kept up to date for each person, and who checks them?
- 03How do you make sure 'as required' medicines have clear instructions and complete administration records?
- 04What refurbishment has been completed in the bathrooms and other tired areas, and what work is still planned?
- 05How are responsibilities shared between the registered manager and the wider management team, including responsibility for sending CQC notifications?
This was an unannounced inspection focused on Safe and Well-led; the other key questions were not rated during this inspection, and the previous overall rating was Good. This explanation was written from the published report of 4 May 2023 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.
What inspectors found, February 2020
Rated Good; inspectors found kind, safe care, with some medication recording and electronic care-plan issues to improve.
This was an unannounced planned inspection on 22 and 23 January 2020. Inspectors observed care, spoke with people, relatives, staff and visiting professionals, and checked care, medication, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were treated kindly, had access to activities and healthcare, and were supported by trained staff.
There were some weaknesses. Medication was mostly managed safely, but some records did not match what had been given and reasons for some medicines were not recorded properly. Care information was sometimes difficult to find while records were being moved to an electronic system.
The overall Good rating was unchanged from the previous inspection, published on 28 July 2017. The provider had already identified the recording issues and had actions planned.
Kind and patient care
Inspectors saw people being cared for patiently and kindly. Relatives said staff treated their family members with dignity and respect.
“We observed care being delivered in the home and saw that this was done in a caring and patient manner.” from the report
Good activities and personal choices
People could take part in activities suited to their interests. Staff adapted the environment and activities when this helped someone feel less agitated.
“There were regular tea dances, themed parties and people had access to two mini buses that were regularly used.” from the report
Food and hydration
People's dietary needs were recorded and catered for. Feedback about the food was positive, and people could choose where to eat.
“People had the option to eat their meals where they chose, and we saw that people enjoyed their food.” from the report
Supported staff and quality checks
Staff were safely recruited, trained and given regular supervision. The provider used audits to monitor quality and identify improvements.
“Staff were recruited safely and received regular training, supervisions, meetings and had regular practice checks.” from the report
Medication recording
needs fixingSome medication records did not match what had been given. Reasons for giving medicines prescribed for use when needed were not always recorded properly, although inspectors found no risk to people at the time.
“There were some examples where medication did not match what was documented on medicine administration records, and reasons for giving the medication were not always recorded appropriately.” from the report
Care information was hard to find
minorThe move from paper records to electronic care plans meant information was sometimes difficult to locate. The provider was working with the electronic care-plan company to address this.
“As the provider was transitioning to an electronic care plan system the information was at times hard to find.” from the report
- 01What changes have you made to ensure medication records match what was given?
- 02How do staff record the reason when giving medicines prescribed for use when needed?
- 03How can staff quickly find the correct care plan and risk information on the electronic system?
- 04What training did staff receive after the medication recording issues were identified?
- 05How will you involve my relative and our family in reviewing and changing the care plan?
This was an unannounced planned inspection covering all five CQC questions and the overall quality and safety of the home. This explanation was written from the published report of 12 February 2020 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.
Every inspection of Redholme Memory Care Limited
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Redholme Memory Care Limited →
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Redholme Memory Care Limited →
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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