Archived: Lindenwood Residential Care Home

Lindenwood Residential Care Home provides accommodation and personal care for up to 16 older people, some of whom were living with dementia. 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. There were 16 people living at the service at the time of our inspection.

We last inspected Lindenwood Residential Care Home in July 2018. At that time, we found one breach of legal requirements and the home was rated 'requires improvement' overall. We had scheduled a date to return to Lindenwood Residential Care Home to check on progress. However, in the intervening period since our last inspection, CQC received information of concern that was of a safeguarding nature. In response to this, we raised a safeguarding alert with the local authority and brought forward this scheduled inspection.

We are currently considering our options in relation to enforcement and will update the section at the end of this report once any action has concluded.

At the time of this inspection there was a manager, however they had not yet registered. 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 previous registered manager had left in November 2018 which the service had notified us of. The service has had several management changes over the previous two years. Shortly after our inspection the provider contacted us to say they had dismissed the manager. The provider confirmed they were actively seeking to recruit a new manager for the home.

We were not assured that systems and process for safeguarding people who used the service from abuse were operated effectively. We looked at the concerns raised and found the provider had not protected people from the risk of harm and abuse. CCTV footage had shown that four care workers were sleeping on duty. The provider had not taken timely decisive action. Furthermore, we found the provider had failed to make safeguarding referrals to the local authority and CQC had not been notified in line with regulatory requirements about this matter.

There had been multiple whistleblowers to CQC since our last inspection. Issues raised included concerns about new care workers not being recruited safely. We found the provider did not have robust recruitment procedures in place to ensure staff employed were of good character and to consider any potential risks in relation to their employment, as we found five staff had been working at the home without a Disclosure and Barring Service check (DBS).

People within the service were not always safe. During our tour of the home we found the fire exit was partially blocked by a stand aid and we found the lounge door presented a danger due to the door automatically swinging closed after 15 seconds. We found no evidence to show the homes passenger lift had been examined to ensure it was safe to use under the 'Lifting Operations and Lifting Equipment Regulations' 1998 (LOLER).

Although staff we spoke with said there were enough staff working in the home, we were not assured there were always sufficient numbers of staff deployed to meet people's needs at all times.

The management of medicine was not always safe, which put people at risk. We found inconsistencies in respect of record keeping and we found people did not always have detailed guidance in place for ‘when required’ medicines.

The provider had not ensured the service was being run in a manner that promoted a caring and respectful culture. Although some staff were attentive and caring in their interactions with people, they were not supporting people in a consistent and planned way. They did not always respond appropriately and in a timely manner to people's needs.

Staff were not always working within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Mental capacity assessments for specific decisions had not been completed and correct legal authorisation had not been sought to deprive people of their liberty.

Accidents and incidents were not always recorded, and appropriate analysis was not undertaken to look for trends to try to prevent future accidents.

People had access to health care professionals specific to their needs. However, we found missed opportunities to provide people with the appropriate advice and support when they were losing weight.

Care plans were difficult to navigate which meant that new staff or agency staff may not easily find the most up to date information on people's care needs. Staff had received training in relation to their role and had the opportunity to meet with their manager. However, we found care staff needed training in managing behaviours that challenged.

Throughout the inspection, we observed numerous examples of positive and caring interactions between staff and people who used the service. However, opportunities for such interactions were limited as staff primarily focused on the delivery of task-based care. Activities were not always person centred and people did not have appropriate opportunities to go out.

Although we were satisfied care and support was delivered in a non-discriminatory way and the rights of people with a protected characteristic were respected. We have made a recommendation that the service consults the CQC's public website and seeks further guidance from the online toolkit entitled 'Equally outstanding: Equality and human rights - good practice resource.'

Complaints were recorded and responded to. The provider had a complaints book that recorded verbal complaints.

The provider was unaware of their responsibilities in relation to the duty of candour, which requires services operate in an open and transparent way. We also received evidence that staff within the service had not always acted open and transparently in relation to issues arising in the service, such as staff sleeping on duty.

There was a lack of leadership and governance at the home. There was a lack of support and coaching for staff and this was reflected in the care they provided. Auditing systems were not robust enough to ensure that the service was compliant with the Health and Social Care Act 2008 and as a result these had not identified the concerns that we found during our inspection. The provider had also failed to notify CQC of important incidents and events.

The overall rating for this service is 'Inadequate' and the service has been placed into 'special measures.'

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not, enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We returned to the service on the 5 October 2017 to complete a focussed inspection and found the service was good in the safe and well led domains. Further information about this inspection can be found in the body of the report.

Lindenwood Residential Care Home is a "care home" providing care for up to 16 people in the New Moston area of Manchester. People in care homes received accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

There were 14 people living at Lindenwood Residential Care Home on the day of inspection.

There was not 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. The previous registered manager had left the organisation in February 2018. The current manager had worked at the organisation since May 2018 and told us that they were beginning to process their registration with the Care Quality Commission (CQC).

At this inspection, we found concerns relating to the stock management of medicines, risk assessments and there had been no fire drills recorded since the last inspection.

Stocks of medicines were not clearly recorded. Medication administration records (MAR) has been completed appropriately.

Amounts of medicines in stock were not clearly recorded, However, we saw that medicines were administered in line with the prescription. Medication administration records (MAR)had been completed appropriately.

Peoples fall risk assessments required further work to assist in the prevention of falls. Nutrition and skin integrity risks were monitored and any concerns reported promptly.

Staff were recruited safely and were aware of their responsibilities in ensuring that people were kept safe. Staff understood safeguarding procedures and could describe action to take in the event of suspecting abuse. Staff felt confident that any allegations they raised would be taken seriously and people living at the home were confident they could raise any concerns they had. Staff were aware of the whistleblowing policy and why it was in place.

Checks of premises were in place and in date. The service had not ensured fire drills were always completed.

Staff were given an induction and training relevant to their job role. Staff felt that training was good and complemented their role and they told us they enjoyed learning. Staff received supervision but it was not regular, however, the new manager was in the process of developing a supervision plan. Staff meetings had not always been held in a timely manner.

The service worked in line with the Mental Capacity Act 2005 (MCA) and people received capacity assessments. Best interest’s meetings were held for people to assist them to make decisions. Staff gained consent from people when supporting them with personal care or administering medicines.

Dementia signage had been introduced throughout the building and there was a secure garden for people to access safely.

A ground floor bathroom was being tuned in to a walk-in shower room. This meant that people had the choice of a shower or bath and could easily access the shower if they have mobility difficulties.

There were caring and kind interactions between staff and people using the service. The manager and registered provider knew people well and the atmosphere was calm and pleasant. People told us the staff were very caring and we observed meaningful conversations, people were laughing and joking.

Care plans were detailed and captured peoples’ personal preferences. Care plans gave information to staff to enable them to support people safely and to ensure they retained independence. A ‘This is me’ document gave life history information and was used as hospital passport to inform health professionals of details to support people while they were in hospital.

There was a programme of activities and an activity organiser to coordinate activities and spend time on a one to one basis with people.

People could be supported at the home at the end of life and the home worked with health professionals to ensure people’s choices were respected. Detailed end of life planning was in place to ensure people had their preferences and choices respected at the end of their life.

The service had received no complaints since the last inspection and a number of compliments had been received thanking the staff for the care received for a relative or friend.

There were audits in place to monitor and improve the service. The manager was developing an action plan of things they wanted to improve.

The service sought feedback on what it offered.

Staff felt well supported by the new manager and the registered provider and both were visible across the home.

Lindenwood is located in the New Moston area of Manchester. The home provides accommodation and personal care for up to 16 people and has 13 bedrooms.

The service was last inspected in April 2017. At that inspection we rated the services requires improvement. This was because we found two breaches of the regulations relating to risk and on-going monitoring. These related to the risk assessment of one person that required additional information to be added to ensure the person’s best interests had been considered and that there was clear guidance in place to ensure that staff took the correct action should an emergency situation arise. We also found a number of risks when we looked around the premises relating to the Control of Substances Hazardous to Health (COSHH) and the build-up of unwanted combustible items in the outhouses and storage areas. Because action had not been taken to register a manager with us in a timely manner we had also placed a limiter on the rating in the well-led section of the report of requires improvement.

Following the inspection in April 2017 we received an action plan from the provider which informed us of what action they intended to take to make the necessary improvements to the service. At this inspection we checked to see what action had been taken to address the breaches in the regulations which are the fundamental standards. We found that improvements had been made.

We found that the registered provider had taken swift action to register a new manager following our inspection. 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.

We found that action had been taken to protect people who use the service and others against the risks associated with the individual care of a person and unsafe or unsuitable premises.

The home was decorated in a comfortable and homely manner. The bedrooms were personalised to the person’s individual taste. There was a large lounge and a dining room on the ground floor. The home had a large user-friendly garden with several seating areas.

We last inspected Lindenwood Residential Care Home in May 2016. At that time, we rated the service as requires improvement. This was because there were several breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. The breaches were in relation to risk assessments, staffing levels, medicines management, the need for consent, staff training safe, person-centred care records and the lack of activities and management systems.

The service had not had a manager who had been registered with the Care Quality Commission (CQC) since the end of March 2016. A manager had been recruited but was yet to register with us. 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.

Because action has not been taken to register with us in a timely manner we have placed a limiter on the rating in the well-led section of this report.

The registered provider following this inspection notified us that the manager had left the service and that one of the deputy manager’s was to register with us. We were also informed that the deputy had submitted their Disclosure and Barring Service (DBS) application to start the registration process with CQC.

During this inspection, we found two breaches of the regulations relating to risk. We found that risk assessments had been put in place since our last inspection, which had sufficient details to guide staff to support people safely. However, we found that one of the risk assessments we saw needed additional information to be added. We also found a number of risks when we looked around the premises that needed to be actioned.

You can see what action we have told the provider to take at the back of the report.

People and their relatives told us Lindenwood provided a safe and friendly environment in which to live. We saw that all staff had been trained in safeguarding principles. When we spoke with staff they told us they knew what to do and understood their responsibilities if they witnessed or suspected abuse or poor practice occurring.

Safe staff recruitment procedures were in place and staffing levels had improved.

An electronic medication system had been put in place since our last inspection to help support staff to manage medicines safely.

We saw that since our last inspection the home had identified two members of staff as infection control champions who had received external training to carry out the role. We saw good hygiene practices, for example, staff wearing appropriate aprons and gloves.

We saw that the home was clean and well maintained. The provider had made numerous investments in the premises. We looked at the service’s maintenance and safety records and saw they were up to date.

The service worked within the principles of the Mental Capacity Act 2005 (MCA). The service undertook assessments on people known or suspected to lack mental capacity to consent to care and treatment and consent to care and treatment was recorded. Applications under the Deprivation of Liberty Safeguards (DoLs) had been made or were in the process of being.

Arrangements for staff training and supervision had improved since our last inspection.

People were supported to eat and drink healthily at the care home. We observed that meals were freshly prepared and that people were always offered a variety of options and had access to drinks.

People had access to health care and social care professionals as required. The registered provider always ensured that people were supported during hospital admissions.

People told us they felt cared for and treated well at the home. We saw frequent and friendly interactions between people who used the service, visitors and staff. The atmosphere at the home was calm and relaxed.

People and visitors spoke positively about the registered provider and the staff. We saw examples of people being treated with dignity and respect.

One of the deputy managers had introduced new person centred plans, which had been developed with people who used the service and their family and friends.

Since our last inspection, we saw that a new activities co-ordinator had been employed so there were more activities being offered at the home. People also enjoyed their own interests.

We saw that the service had a complaints policy in place and the complaints procedure was displayed in the main hallway. We noted that the service had not received any complaints since our last inspection. The local commissioning team raised no concerns with us.

We observed that the registered provider and the manager were very visible within the service. People, visitors and staff said the registered provider and the manager were both approachable and supportive.

Since our last inspection, significant improvements had been made in relation to the breaches in the regulations, which are the fundamental standards. Systems for monitoring the health, safety and quality of the service had been put in place; however, in they were not robust enough to identify the shortfalls we found at this inspection.

The CQC had notified about incidents that had occurred at the home.

The home is decorated in a comfortable and homely manner. The bedrooms are spacious and well presented. There is a large lounge and a dining room on the ground floor; most of the people living at Lindenwood. The home also has well maintained outdoor spaces including a large accessible garden with several seating areas.

We last inspected Lindenwood Residential Care Home in November 2014. At that time, we rated the service as Inadequate. This was because there were several breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2010. The breaches were in relation to safe staffing levels, safe recruitment of care staff, safe and effective person-centred care, need for consent, and complaints. At this inspection we checked to see if improvements had been made in all the areas we identified. We found that whilst some issues had been addressed either fully or partially, others had not and remained outstanding.

The service had not had a manager who had been registered with the Care Quality Commission (CQC) since the end of March 2016. A manager had been recruited and was presently applying to be registered. 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.

We found breaches of regulations. You can see what action we have told the provider to take at the back of the report.

People and their relatives told us Lindenwood provided a safe and friendly environment in which to live. We saw that all staff had been trained in safeguarding principles. When we spoke with them they told us they knew what to do if they saw abuse occurring. We saw evidence of this when a previous safeguarding incident had occurred.

We found that risk assessments were not always in place and, when they were, they did not have sufficient and specific details to guide staff to support people safely. We did not see any personal emergency evacuation plans in place. We were told that these were being updated. We found examples of poor practice regarding the storage of prescribed ‘thickener’ medicines and the lack of information for people with special diets such as diabetic meals. Thickener medicines are added to drinks, and sometimes to food, for people who have difficulty swallowing;

Staffing levels had improved slightly since the previous inspection. However, we found at certain times during the day there was not always enough staff to effectively attend to everyone’s needs. We saw that the care home had recruited two new care workers but another worker had recently left the service. The manager told us they had advertised online and we saw they had received several applications.

The service had safe recruitment procedures in place and we were satisfied that all necessary criminal records and reference checks had been done to ensure that care staff were fit for the job they were recruited to do.

The CQC had not been notified of all safeguarding incidents that had occurred at the home.

We saw that medicines administration was safe and that staff had been appropriately trained. The home kept a locked medicines fridge which was monitored satisfactorily. There was a generic policy in place for medicines administration and this included the administration of covert and ‘as needed’ (or PRN) medicines, but there were no PRN protocols to help guide staff in administering this type of medicine.

We observed that the home was clean and well maintained with no malodorous smells. We did not see any evidence that Lindenwood did its own infection control audits or spot checks. We saw staff observing good hygiene practices, for example wearing aprons and gloves. We noted that the local authority had done an infection control audit in March 2015 and that there were several areas the home had not yet actioned.

We looked at the service’s maintenance and safety records and were satisfied that all checks had been done and these were up to date.

The service did not always work within the principles of the Mental Capacity Act 2005 (MCA). The service did not undertake assessments on people known or suspected to lack mental capacity to consent to care and treatment. There seemed to be a lack of knowledge and understanding about the impact this legislation could have on people’s consent to care and support. Applications under the Deprivation of Liberty Safeguards had been made.

People told us they had confidence in their care workers’ abilities. We saw that mandatory training had been done. This included health and safety and moving and handling. We saw that staff training was ongoing but that for most staff several areas of their mandatory training were now due for an update. Staff had recently had supervision with the manager and we saw that supervisions and an annual appraisal had been scheduled up to December 2016.

People were supported to eat and drink healthily at the care home. We observed that meals were freshly prepared and that people were always offered a variety of options.

People’s access to health care professionals was good. We noted that the owner ensured that people received the right care at the right time. During our visit, a speech and language therapist was visiting and they said that the home was very proactive in making referrals.

People told us they felt cared for and treated well at the home. They commended staff and the owner. We witnessed several caring interactions between people and the care staff and the owner throughout our inspection. People told us they were treated with dignity and respect and we saw examples of this while we were there.

We saw that people’s views were sought when they attended a residents’ meeting held in April 2016. People were kept informed of developments at the home such as new staff being recruited and they were able to give their opinions on what could be improved. The manager was hoping to enlist the help of a neighbourhood group to provide advocacy services, if needed.

Person-centred plans were not yet fully embedded at the service. The manager told us that they were in the process of updating these. This meant that we could not be sure that staff would know what was important to a person and be able to support them appropriately.

There were few structured activities or recreation offered at the home. Several people told us they were bored. We saw that staff sometimes asked people if they wanted to participate in sing-alongs but most times people either watched television or listened to music. We observed some people listening to their own music through headphones, doing colouring or chatting with others.

We saw that the service had a complaints policy in place and the complaints procedure was displayed in the main hallway. We noted that the service had not had many complaints but that a concern raised by a relative had been dealt with promptly and to their satisfaction.

People and their relatives told us they thought the care home to be a good one and that it was well run. We observed that the owner and the manager were very visible within the service.

Since the last inspection, the service had made some improvements and these were either fully or partially completed. However, in other areas, improvements were not made; this was evidenced by on-going breaches of the regulations identified within the report, such as quality assurance systems, staffing levels and rota management.

We saw there were appropriate policies and procedures in place to provide guidance and support to staff in performing their role effectively. However,

Staff meetings had been reinstated and we noted that staff morale seemed to be good. Staff were complimentary about the new manager, saying that they felt supported by them. Staff also told us that the owner was also very supportive.

Below is a summary of what we found. The summary is based on our observations, talking with people living in the home and with staff and with the acting manager. We also looked at care records and other files.

The evidence that supports our summary can be found in our full report.

Is the service safe?

One person told us: "I like it living here. I feel comfortable." We found equipment was now being used safely, following our previous inspection. We found that the premises were well designed to minimise risks, although we did comment on the need to keep the stair gates closed and locked at all times.

At the date of our visit no applications for authorisations under DoLS (the deprivation of liberty safeguards) had been made. No mental capacity assessments had been done. The acting manager stated that Lindenwood intended to introduce these where approprate.

Is the service caring?

In the visitors' book someone had written: "Wonderful home, a lot of love here, very proud."

We saw that staff had built up close relationships with people, some of whom had been living in the home for several years.

There was a family-like atmosphere within the home, because of the small number of people living there. We saw that some people had built up friendships and some people helped others, for example at mealtimes.

Is the service responsive?

We learnt that the provider always accompanied people to hospital and responded to their health needs. We found that Lindenwood had responded to the findings of our previous report by using equipment correctly and obtaining new equipment. The home had also increased its staffing levels at certain times of the day, although we considered there was more to do in this respect.

Is the service well-led?

At the time of our visit there was no registered manager. The acting manager had been in post for a year, and improved many aspects of the running of the home. A new manager had been appointed and would be applying to become registered manager.

The owner/provider was always present within the home and took a keen interest in the welfare of the people living there.

Is the service effective?

The people living in Lindenwood had a variety of needs. Some were living with dementia. Others had very limited mobility. The service was effective in creating a caring environment for their various needs. Their physical needs were cared for, the food was nutritious and wholesome, and staff were caring and compassionate. Some of the people could benefit from a wider range of activities. Staff were being well supported to deliver care.

During our inspection we spoke to two people living in the home. One of them said: "It's very nice here. I wouldn't like to live anywhere else."

We found that the provider was not ensuring the welfare and safety of some of the people living in the home because they had not carried out an assessment of their needs in relation to being moved safely. The provider was not ensuring their welfare and safety because they were not using equipment to move those people and had not replaced broken equipment.

We also found that the provider was not ensuring that there were sufficient numbers of suitable qualified staff on duty at all times.

We therefore found that the provider was non-compliant with the standards in the two areas we looked at during this inspection.

We also spoke with relatives who were visiting people living in Lindenwood. One described the home as "a tremendous place. If I wasn't happy I'd say so. The staff are great."

Another visitor said: "The staff are fantastic. They are helpful. I always know what's going on."

We conducted an observation at lunchtime in the lounge and noted that the quality of care and assistance given to people was good. We found that nutritious and wholesome meals were provided. One resident we spoke to said "The food is very good." Appropriate help was given to people who were having difficulty eating.

After our last inspection we asked Lindenwood to make improvements in two areas. We found that the home had introduced new procedures and documents. These meant that they were now meeting the regulations relating to obtaining consent for treatment, and providing risk assessments.

We found that the procedures for recruiting staff were satisfactory, and that Lindenwood had effective systems to monitor the quality of the service and to assure the health and welfare of people living in the home.

We spoke with three people who were visiting friends or relatives who live in the home. All were pleased with the care and support being provided. One person said 'It is absolutely fantastic. The staff are dedicated and the service provided is very homely.' Another relative told us they were always made to feel welcome when they visited and felt fully involved in their relative's care.

All the staff we spoke to told us there were sufficient staff to meet people's needs. One care worker said 'The staffing levels here are very good. It means you have quality time you can spend with the residents.' People we spoke with told us that staff provide them with the support they need. From our observations of the care being delivered during the day there appeared to be enough members of staff to meet people's care and support needs.