Lindisfarne CLS Residential

Lindisfarne CLS Residential is a care home which provides nursing and residential care for up to 30 people. The service provides support to older people, people living with dementia and physical disabilities. At the time of our inspection, 26 people were living at this service.

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

People were satisfied with the service and felt staff always went above and beyond in delivering the care. They described the little extras staff just did as a part of their job. Staff were passionate about providing good care outcomes and took ownership for their practice.

Risk assessments were clear and readily identified how to reduce the risks to people. Staff were familiar with these documents and the actions they needed to take. We discussed how to enhance and develop some aspects of these documents, which the registered manager and deputy manager immediately acted upon.

The management team ensured there was always enough staff to support people. The nature of the service meant the number of people living at the home could rapidly fluctuate. On reviewing the staffing levels, it was decided to increase the number of staff, on duty so these variations could be managed more effectively. Recruitment practices met legal requirements and the registered manager used a variety of effective strategies to encourage people to apply to work at the service.

Medicines management was effective and closely monitored. Staff who administered medicines had the appropriate training. Staff adhered to infection control and prevention guidance.

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. Staff had received training around the Mental Capacity Act 2005 and associated code of practice and felt confident applying this in their practice. Staff took steps to safeguard people and promote their human rights.

The systems the registered manager had in place allowed them to critically review the service and proactively looked at how improvements could be made. Staff told us the registered manager was approachable and listened to their views. All felt the registered manager was running a good service.

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 good (published 16 February 2019).

In January 2021 we completed a focused inspection looking at infection control and prevention practice and were assured staff followed guidance appropriately.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

This report only covers our findings in relation to the key questions safe and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

¿ Systems were in place to help prevent people, staff and visitors from catching and spreading infection.

¿ There was enough PPE such as aprons, gloves and masks. Staff were wearing this appropriately when we visited. Staff had undertaken training in putting on and taking off PPE.

¿ Staff and people were tested regularly for COVID-19. A COVID-19 vaccination programme was in place.

¿ Staff had worked as a team to help promote people’s wellbeing throughout the pandemic. We observed positive interactions between staff and people.

Further information is in the detailed findings below.

This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Lindisfarne CLS Residential is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates 30 older people across two floors. At the time of the inspection 23 people were being supported in the home.

The service had 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 provider had a system in place to ensure the safe recruitment of new staff. Appropriate checks were made prior to commencement of employment.

The provider had policies and procedures in place to keep people safe. Staff were trained in safeguarding and knew how to report concerns. Staff felt the provider would act to ensure people’s safety.

Accidents and incidents were recorded and monitored for themes and patterns to reduce reoccurrences.

Risks to people and the environment were assessed with control measures in place for staff support and guidance. Risk assessments were reviewed on a regular basis

Policies and procedures were in place to support staff in the safe management of medicines. Medicine administration records (MARs) were completed correctly.

The registered manager had a process in place to ensure staffing levels were sufficient to meet people’s needs. Staff felt supported, were appropriately trained and received regular supervisions and appraisals.

People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People enjoyed a varied diet and had their nutritional needs assessed regularly. When necessary staff ensured people had access to health care professionals.

Staff treated people with dignity and respect. People’s independence was promoted. People’s privacy was maintained.

Care plans were personalised and reviewed on a regular basis. People were involved in planning their support. People were supported at the end of their lives with staff ensuring wishes and preferences were upheld.

People had access to a range of activities both in and outside the home.

The provider had a complaints procedure in place. People who used the service and their relatives were aware of how to make a complaint.

Health and safety checks were completed regularly and records maintained.

The registered manager worked with local commissioners and other stakeholders. Community links were maintained with people accessing local amenities in a regular basis. Members of the clergy made regular visits to the home.

The provider had an effective quality assurance process in place and maintained a development plan to drive improvements.

Lindisfarne Chester-le-Street Residential provides accommodation for up to 30 people who require personal care. It does not provide nursing care. The home is set in its own gardens in a residential area near to public transport routes, local shops and facilities.

At the last inspection in September 2013 we found there was a breach of Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010 – Premises. We asked the provider to take action to make improvements to the premises and this action had been completed.

There was a registered manager in post. 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.

Staff who worked in the home had undergone the required checks to ensure they were fit to work with vulnerable adults.

We found staff had been appropriately trained to give people who used the service their medicines and staff had been checked to see if they were competent to do this.

There were regular checks including fire checks carried out in the building to ensure people who used the service were kept safe in the home.

Staff had been trained in safeguarding and any concerns about people were checked when the registered manager met staff for supervision meetings.

The home met the requirements of the Mental Capacity Act (MCA) and had made appropriate applications to the required body to deprive people of their liberty, where it was in their best interests to do so, and to keep them safe.

We checked people’s weights and found that people who used the service had maintained their weight. This meant their food intake met their needs.

Relatives and people living in the home described the staff as very caring. We observed staff treating people with dignity and respect. Staff were able to support and calm people who were distressed.

We saw people’s care plans were person centred and contained information specific to them. The care plans provided detailed information and guidance to staff to enable them to provide the right care for people.

The registered manager had put in place one page documents which detailed each person’s like and dislikes as well as the sentences they would use to discuss issues. Staff were guided on how to work with people in a positive, encouraging fashion which avoid undermining their confidence and well-being.

Staff engaged with people who used the service during the inspection and provided activities throughout the day. We saw people respond positively to staff who spent time with individual people.

There had been no complaints since our last inspection. We found people knew how to make a complaint but they told us they had not felt the need to raise any concerns.

The manager used six values with the staff to drive the service. They were care, compassion, competence, communication, courage and commitment.

Compliments were given to us from relatives, people who used the service and staff about the manager.

We found the registered manager had carried out surveys to monitor the quality of the service. The surveys showed people were largely positive about the service.

We found the service worked with other professionals and family members to meet people’s needs.

We found care and treatment was planned and delivered in a way which ensured people's safety and welfare. One person who lived at the home told us, 'I didn't want to come here but my life has been so much better now that I have. I'm so pleased with the help and support they (staff) have given me. Another person said, 'No matter what, they (staff) are happy and that makes me happy.'

We found the provider had not taken steps to provide care in an environment that was adequately maintained.

The provider had made suitable arrangements to protect vulnerable people and respond appropriately to any allegation of abuse.

The provider had taken steps to make sure people at the home were protected from staff who were unsuitable to work with vulnerable people by carrying out thorough background checks.

We found the provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and promote their health and wellbeing.

We found care and treatment at the home was planned and delivered in a way which ensured people's safety and welfare. A community psychiatric nurse assistant who was visiting people told us she felt confident the home was able to effectively support peoples' mental health needs.

We looked at the way medication was handled at the home and found people were protected against the risks of unsafe use or management of medicines because the provider had appropriate arrangements in place.

We found staff received appropriate professional development. People told us they were happy with the support they received from staff. One relative said, 'The staff here are all excellent, I don't have to worry about my (relatives) care because I know they will look after her as good, or better than I could.'

We found people who used the service, their representatives and staff were asked for their views about the care and treatment offered. Their responses were acknowledged and acted on. People at the home said they liked 'the girls,' the 'happy family' and it was 'nice and warm.'