Lindisfarne Crawcrook

Lindisfarne Crawcrook is a care home providing accommodation and personal and nursing care to up to 60 older people, including people who may live with dementia, or a dementia related condition. At the time of our inspection there were 51 people using the service, living in one purpose-built building.

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

At our last inspection the provider did not have effective systems in place to monitor and improve the quality of the service and improvements were required to medicines records. At this inspection some improvements had been made, medicines were better managed and improvements had been made to medicines records, but other improvements were needed to the running of the service to ensure people received safe, timely and person-centred care.

Further action was required with regards to the provider’s quality monitoring system. We identified shortfalls with staffing levels and staff deployment, the provision of person-centred care, the environmental design, people’s mealtime experience and communication. These shortfalls had not all been identified or actioned in a timely manner by the provider’s governance system.

Improvements were required to the environment to ensure it was designed to meet the needs of people who live with dementia, to keep them orientated and engaged as they walked around. People’s mealtime experience was not well-managed to ensure, people were offered choice and encouragement to eat.

Staffing levels and staff deployment were not effective to ensure people received safe, timely and person-centred care. Care was task-centred rather than person-centred. Due to staff being busy they did not have time to spend with people. Throughout our observations some people sat silently or were not engaged or stimulated. We have made a recommendation staff receive training about person-centred care.

Risks to people’s safety was not well-managed, staff did not always identify, or take action to mitigate the risk of avoidable harm. Where people may become upset or agitated, their distress was not always understood or well-managed.

Records provided guidance to assist staff to deliver care and support to meet people’s needs. Staff recruitment was carried out safely and effectively. There was evidence of collaborative working and communication with other professionals to help meet people's needs. People and relatives had opportunities to give feedback about the service.

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.

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 requires improvement (published 31 August 2022).

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.

At our last inspection we recommended that the provider continued to keep staffing levels under review to ensure people receive timely and person-centred care. We recommended to continue with a timely programme of refurbishment to keep people engaged and to maintain the cleanliness of the home. At this inspection we found the provider had not acted on all the recommendations to make improvements.

The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections. We will describe what we will do about the repeat requires improvement in the follow up section below.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 13 July 2022. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance and the management of medicines records.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective and well-led which contain those requirements.

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 inspected and found there were concerns with people’s dining experience, environmental design and staff training, so we widened the scope of the inspection to include the key question effective.

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 remained requires improvement 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.

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 Lindisfarne Crawcrook on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to staffing, safe care and treatment and governance.

We have made a recommendation that staff receive further training to give them more insight into people's care and support needs.

Follow up

We will meet with the provider following this report being published 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.

Lindisfarne Crawcrook is a care home providing personal and nursing care to up to 60 people. The service provides support to older people including people who live with a dementia. At the time of our inspection there were 44 people using the service.

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

At our last inspection the provider had failed to robustly manage the risks relating to the health safety and welfare of people, including managing people’s medicines safely.

At this inspection improvements had been made and the service was no longer in breach of the regulation safe care and treatment as systems were becoming more robust to minimise the risk of harm to people.

Whilst improvements had been made since our last inspection in relation to the assessment and management of risk; at this inspection, further action was required with regards to the provider’s quality monitoring system. We identified shortfalls with the recording of medicines, staff deployment, the provision of person centred care and the environment. These shortfalls had not all been identified or actioned in a timely manner by the provider’s governance system.

People were safe but there were insufficient staff to support people in a timely and person-centred way. We have made a recommendation about this.

An infection control system was in place. However, not all areas of the home were well-maintained or clean and there were signs of wear and tear. We have made a recommendation about continuing with the programme of refurbishment in a timely manner, ensuring the environment is appropriately designed to meet all people’s needs and an appropriate standard of hygiene is maintained.

A quality assurance system was in place, but it needed to become more robust to assess the standards of care in the service. Improvements were needed to the running of the service to ensure people were the main focus of care delivery and they received person-centred care.

All people and relatives were complimentary about the direct care provided by staff. They trusted the staff who supported them. They said staff, although, “very busy”, were kind and caring and supportive of people and their families.

Most records provided detailed guidance to assist staff to deliver care and support to meet people’s needs. Risks were assessed and mitigated to keep people safe. Staff recruitment was carried out safely and effectively.

The provider was monitoring the use of PPE for effectiveness and people’s safely.

There was evidence of collaborative working and communication with other professionals to help meet people's 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.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 27 August 2021) and there was a breach of regulation 12 (Safe care and treatment). 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 that action had been taken in relation to regulation 12 and the provider was no longer in breach of this regulation. However, further improvements were required. Please see the safe and well-led sections of the full report.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan since the last inspection and to confirm they now met legal requirements. The inspection was also prompted in part due to concerns received about the high incidence of falls to people and staffing. A decision was made for us to inspect and examine those risks. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 has taken action to mitigate risks to promote people's safety but still needs to make improvements. Please see the safe and well-led sections of this report.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation regulation 17 (Good Governance).

You can see what action we have asked the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lindisfarne Crawcrook 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.

Lindisfarne Crawcrook provides personal and nursing care for up to 60 older people and people living with dementia. At the time of this inspection 53 people were living at the service.

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

Relatives felt communication could be improved particularly around responding to questions. Interactions we saw between people and the staff team were very positive. The area manager was working with staff to improve their communication techniques.

People were treated with kindness, dignity and respect. People told us the care was safe and they were happy at Lindisfarne Crawcrook.

A review by the provider and visiting professionals identified improvements were needed. The provider had deployed a range of additional resources, such as two area managers and maintenance team to the home to support staff make the necessary improvements.

The provider and area manager were in the process of improving medicines management. Further action was needed to ensure all the identified improvements were made and then changes in practice embedded.

Care staff, in general, adhered to COVID-19 guidance on working in a care setting. Staff had undertaken training in putting on and taking off PPE, but this needed to be refreshed. The area manager immediately ensured staff received additional infection, prevention and control training.

Overall people were protected from harm as risks had been assessed and plans put in place to mitigate these. They provided staff with guidance on the actions to take to reduce the risk but at times this needed to be more detailed and cover all risks. Staff working with people on the residential unit needed clearer guidance around when to contact health professionals if people’s needs changed.

People’s care records were in the process of being reviewed to ensure they reflected people’s current needs.

People were protected from abuse by staff who understood how to identify and report any concerns. The area manager was ensuring all appropriate referrals were made to the safeguarding team.

The provider’s governance arrangements had identified improvements were needed in the home. The provider had employed external parties to undertake additional audits in the home. These had failed to pick up gaps in staff practices identified through the auditing process. The area manager was working with staff to change the culture at the home and equip staff with the confidence to take ownership for all aspects of the day-to-day management of the home.

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 10 May 2019).

Why we inspected

The inspection was prompted in part due to concerns received about managerial oversight, medicines management and record keeping. A decision was made for us to inspect and examine those risks. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified a breach of regulation in relation to managing the risks to people’s health and safety at this inspection. Please see the action we have told the provider to take at the end of this report.

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.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service: Staff were making a difference to people’s wellbeing by working well as a team, in harmony with one another and by sharing the same values and principles.

We found that staff were totally committed to delivering a service which improved people’s lives in fulfilling and creative ways. Their drive and passion had created a dynamic and vibrant service.

Staff focused fully on the goals and aspirations of the people who used the service. People on the downstairs unit told us that the staff had enabled them to rebuild their relationships with family members and this meant a great deal to them.

Staff took steps to safeguard vulnerable adults and promoted their human rights. Incidents were dealt with appropriately, which helped to keep people safe. People’s health needs were identified and external professionals involved if necessary.

People participated in a range of activities that met their individual choices and preferences. Staff understood the importance of this and provided the structured support people required. This enabled people to achieve positive outcomes and promoted a good quality of life.

Staffing levels met people’s needs. Staff had received a wide range of training including around working with people who may display behaviours that challenge. Checks were made on the ongoing competency of staff.

The cook and staff had received ‘focus on under-nutrition’ training. Staff were encouraging people who were under-weight to eat fortified foods. A range of menu choices were available.

People participated in a range of activities that met their individual choices and preferences. Staff provided the structured support people required.

The registered manager had acted on concerns and complaints and had taken steps to resolve these matters. All incidents were analysed and lessons were learnt and embedded into practice.

The service was well run. The senior managers and registered manager carried out lots of checks to make sure that the service was effective. The registered manager continually researched information about best practice and ensured staff practice remained at the forefront in introducing new guidance.

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

Rating at last inspection: Good (report published 20 September 2016).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Lindisfarne Crawcrook provides personal and nursing care to a maximum of 60 older people, including people who live with dementia or dementia related conditions.

A registered manager was 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.

We last inspected Lindisfarne Crawcrook in August 2015. At that inspection we found the service was in breach of its legal requirements with regard to person centred care, premises and equipment, good governance and staffing. This was because records did not contain all the information needed to ensure people received appropriate care that met their needs. The auditing arrangements were not effective to ensure people received appropriate care. Arrangements were not in place to ensure people enjoyed a pleasant dining experience to support their nutrition and hydration. Standards of hygiene were not always satisfactory and the home was not well maintained and designed for the needs of people who lived there.

Due to their health conditions and complex needs not all people were able to share their views about the service they received. Those that could speak with us told us that care was provided with kindness and we observed that people’s privacy and dignity were respected. Staff knew the people they were supporting well.

We found improvements had been made to ensure the safe care and treatment of people. People told us they felt safe and there were enough staff on duty. Staffing had been reviewed and increased so staff now had more time to interact and spend time with people and not just when they carried out tasks.

Risk assessments were in place and they accurately identified current risks to the person as well as ways for staff to minimise or appropriately manage those risks. People were protected as staff had received training about safeguarding and knew how to respond to any allegation of abuse. Staff received opportunities for training to meet peoples’ care needs and in a safe way. A system was in place for staff to receive supervision and appraisal and there were robust recruitment processes being used when staff were employed.

Staff had received training and had a good understanding of the Mental Capacity Act 2005 and best interest decision making, when people were unable to make decisions themselves. People were able to make choices where they were able about aspects of their daily lives. People had access to health care professionals to make sure they received appropriate care and treatment. Staff followed advice given by professionals to make sure people received the care they needed. People received their medicines in a safe and timely way.

A complaints procedure was available. People told us they felt confident to speak to staff about any concerns if they needed to. Staff and people who used the service said the registered manager was supportive and approachable. People had the opportunity to give their views about the service. Feedback was acted upon in order to ensure improvements were made to the service when required. The provider undertook a range of audits to check on the quality of care provided. Records had been updated and they were regularly reviewed to reflect peoples’ care and support requirements.

Changes had been made to the environment. It was cleaner and brighter and areas had been refurbished. Menus were varied and a choice was offered at each mealtime. Staff supported people who required help to eat and drink and special diets were catered for. Some activities and entertainment were available for people and people were being consulted to increase the variety of activities and outings.

. Is the service safe?

. Is the service effective?

. Is the service caring?

. Is the service responsive?

. Is the service well-led?

This is the summary of what we found.

Is the service safe?

An assessment of people's care and support needs was carried out before people started to use the service. This was to ensure staff had the skills and had received the training in order to meet the person's support requirements.

Risk assessments were in place. People were supported and encouraged to maintain their independence and this was balanced with the risk to the person. Audits were carried out to look at accidents and incidents and the necessary action was taken to keep people safe.

Information was available to show that the service worked with other agencies to try to prevent admissions to hospital wherever possible.

Regular checks of fire equipment and fire drills were carried out to ensure the safety of people who used the service and staff. There were currently enough staff on duty to meet the needs of the people who used the service. The number of domestic staff needs to be kept under review as occupancy levels increase to ensure a clean and hygienic environment at all times.

Is the service effective?

People we spoke with were positive about the service provided. People commented how helpful and friendly the workers were. Relatives told us the service kept them up to date with what was happening with their relative's care and they felt able to ask any questions.

Staff we spoke with were knowledgeable about people's care needs. They had received training to help them understand the different care and support needs of people they worked with. Staff who worked with people who lived with dementia were observed to be patient and supportive as they worked with people. This was particularly noticeable in the top floor lounges where there was an excellent camaraderie and staff were enthusiastic and interacted with people at all times. This was not evident in the main downstairs lounge where people sat without any interaction, when the activities organiser was not present, and the member of staff sat reading a magazine.

Is the service caring?

People and relatives spoken with talked well of the level of care provided by staff. Comments included; "My wife has settled well here, much more than the last place she was." We found people were encouraged to be involved in daily decision making. Staff were helpful and offered people information and support about their care. People said they could ask questions if they were not sure what was happening to them or raise any concerns with staff who were all very approachable.

People who used the service were always accompanied by a person to hospital, if a visit was necessary, and the worker stayed with them until a family member arrived or they were admitted to a ward. This was to ensure that hospital staff could be given all the appropriate information and to support the person during their hospital appointment or admission.

Is the service responsive?

Information was collected by the service with regard to the person's ability and level of independence before they moved into the service. Various assessments were completed by the manager of the service with the person and/or their family to help make sure staff could meet their needs. Regular reviews were carried out with the person who used the service and their representative to make sure the person's care and support needs had not changed. This helped ensure staff supplied the correct amount of care and support.

Referrals for specialist advice where made when staff needed guidance to ensure the health needs of people were met.

People's individual needs were taken into account and they, or their representative if they were not able, were involved in all decision making with regard to their care. They were kept informed and given information to help them understand the care and choices available to them.

Information collected by the service gave staff some insight into the interests and areas of importance to the person. It helped with the provision of social activities people may wish to be involved with.

Regular meetings took place with staff to discuss the running of the service and to ensure the service was responsive in meeting the changing needs of people.

Is the service well-led?

There was a focus from management on the provision of individual care and support to people who use the service. Staff were knowledgeable about the support needs of people.

Staff received regular supervision and commented they felt supported by the management team and advice and support was available from the management team.

We saw people had the opportunity to comment on the quality of the service and that they felt able to speak to the manager and staff about any issues. Survey comments included; " The home is well managed." Two people commented however they did not feel confident any action would be taken; "Approachable but little seems to get done." And; "Listen then nothing done." This was also apparent at the time of inspection as safety gates against some people's doors were still in use despite previous inspections highlighting it was not good practice to use them.

Some relatives we spoke with were appreciative of the care provided by the home. One person said;" My mother has always been happy at the home thanks to the constant kindness and care of the staff." Another person said; "My father has settled very well here thanks to the staff, they are excellent."

Records showed care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

We found staffing levels had increased at night which ensured there were enough qualified, skilled and experienced staff to meet people's needs.

The premises were better maintained so people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We saw the provider had an effective system to regularly assess and monitor the quality of service that people received.

We used a number of different methods which included observation to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences.

We saw staff were very busy as they provided care and support to people who used the service. We spoke to three people who lived at the home and one relative who told us staff were kind and helpful but they were kept very busy.

We observed staff were rushed as they tried to provide individual care to each person. Due to the low staff numbers on duty and the high dependency of many people care and support was not provided in a timely way as people had to wait for staff support. At times they were at risk due to inadequate observation. We also saw some people were not able to have choice when to get up in the morning.

We found the building was not well maintained or suitably designed for the needs of people with dementia.

We saw the provider had some systems in place to gather feedback from people, who used the service, and to regularly assess and monitor the quality of service people received.