This inspection took place on the 3 and 5 July 2018, the first day being unannounced. Flixton Manor 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.

Flixton Manor is registered to provide accommodation with personal and / or nursing care for up to 38 older people. At the time of our inspection there were 36 people living at the home, the majority of whom were living with dementia. Accommodation is provided over three floors, including a basement level, ground floor and first floor. 36 bedrooms are single occupancy. One double room is available if a couple wish to share; however, this is usually used as a single room. Newer bedrooms have an en-suite toilet. There are two communal lounges and a small dining area on the ground floor.

At our last inspection in June 2017 we found three breaches of regulations with regard to the use of unsafe moving and handling techniques, a lack of staff interaction when supporting people and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, caring and well led to at least good. At this inspection we found improvements had been made and these regulations were now being met.

Flixton Manor 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.

We observed staff engaging with people throughout the inspection. Staff sought people’s permission before providing support and explained to people the support they were about to provide. We observed safe moving and handling techniques being used.

A quality audit system was in place to monitor the service. Daily walk arounds had been introduced to observe staff and check around the building. The observations were documented and we saw positive feedback had been given to staff where good practice had been seen.

People and their relatives thought they were safe living at Flixton Manor. The staff said they enjoyed working for the service and felt well supported by management team.

People received their medicines as prescribed. Guidelines for when a person may require a medicine that was not routinely administered (PRN) were not always in place.

Staff added thickener to fluids where people had been assessed as being at risk of choking. However, they did not document when they had done so. The registered manager said they would introduce a form for staff to sign when they added thickeners to fluids.

We have made a recommendation that best practice guidelines are followed for the recording of variable dose medicines.

Care plans and risk assessments were in place which provided guidance and information about people’s support needs, their likes, dislikes and preferences and how to mitigate the identified risks. Staff we spoke with knew people and their needs well. Care files were reviewed each month.

A pre-admission assessment was completed when people moved to the home. Key information about a person’s needs was identified and written up for the staff to refer to. However, initial care plans and risk assessments were not written for around two weeks after the person moved to Flixton Manor so they had time to get to know their needs better. We have made a recommendation that the service follows best practice guidelines in developing initial risk assessments and care plans in a timely manner.

People were supported with their health and nutritional needs. A health professional told us the pressure area care at the home was good. Th

This inspection took place on the 2 and 3 May 2017 and was unannounced, which means they did not know we were coming.

Flixton Manor is registered to provide accommodation with personal care with nursing for up to 38 older people. At the time of our inspection there were 34 people living at the home, the majority of whom were living with dementia. Accommodation is provided over three floors, including a basement level, ground floor and first floor. All bedrooms are single occupancy. Newer bedrooms have an en-suite toilet. There are two communal lounges and a small dining area on the ground floor.

The service had a registered manager who had been in place since September 2016. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 inspection took place in September 2016 where six breaches of the Health and Social Care Act 2008 were identified. The provider was placed into special measures by the CQC. We took enforcement action and issued two warning notices to the provider.

This inspection was carried out to check what improvements had been implemented since our last inspection. We found that improvements had been made and these were sufficient for the CQC to be able to take the service out of special measures.

People and their relatives told us they felt safe living at Flixton Manor. Staff had undertaken training in safeguarding vulnerable adults and were able to describe the different types of abuse and how they would report any concerns.

The number of staff on duty in the morning had been increased since our last inspection. However we noted that staff were very busy and task orientated. People and relatives told us they sometimes had to wait for staff to be available to support them to use the toilet. However other relatives told us their loved ones always looked well cared for.

Staff had little time to speak with and interact with people. We observed that some staff interacted well with people when they were supporting them, whilst others did not. The management team at Flixton Manor were aware of this and had taken some steps to address this issue.

We saw no activities taking place during our inspection although an activities officer was due to start work at the service in June 2017. They would be able to interact with people and organise activities for people to participate in. The activities officer was also due to complete details of people’s life histories. We did note that more external entertainers were now being arranged to come to the home. People had daily papers available and the home had Sky TV installed which some people enjoyed for watching football.

The care plans and risk assessments had been reviewed and any duplication removed. They provided clear person centred guidance for staff to follow in order to meet people’s care needs.

Staff had completed training to give them the knowledge to undertake their roles. However we observed three occasions of an unsafe moving and handling procedure (called a drag lift). We have made a recommendation for the service’s moving and handling training is reviewed so it meets current best practice guidance for safe moving and handling techniques.

Team meetings and staff supervisions had been introduced. This meant staff were better supported in their roles.

Handovers were held between each shift to update the staff on any changes in people’s needs or health. This meant staff had the information to support people and meet their needs.

The staff recruitment procedure had been improved so staff were safely recruited who were suitable to work with vulnerable people.

We saw medicines were administered as prescribed. Guidelines for any ‘as required’ medicines such as pain r

This inspection took place on the 6 and 7 September 2016 and was unannounced.

Flixton Manor is registered to provide accommodation with personal care with nursing for up to 38 older people. At the time of our inspection there were 33 people living at the home, the majority of whom were living with dementia. Accommodation is provided over three floors, including a basement level, ground floor and first floor. All bedrooms are single occupancy. Newer bedrooms have an en-suite toilet. There are two communal lounges and a small dining area on the ground floor.

The previous inspection took place in September 2014. We found four of the standards we looked at were met; however we found care plans did not include written assessments of people’s capacity to consent to their care and treatment at Flixton Manor. Following the inspection in September 2014 the provider wrote to us to tell us the action they intended to take to ensure they met all the relevant regulations. Part of this inspection was undertaken to check whether the required improvements had been made. We found improvements had been made in relation to undertaking capacity assessments for people living at Flixton Manor.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 registered manager was due to retire shortly after our inspection. A senior carer who had worked at the home for many years had been appointed as the new manager and was applying to be registered with the CQC.

During this inspection visit we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to recruitment processes, training and staff supervision, lack of staff interaction with people who used the service, assessments and reviews of care, managing complaints, meeting people's social needs and quality assurance and auditing systems. We also found breaches of the Care Quality Commission (Registration) Regulations 2009 relating to not submitting the required notifications to the CQC. A notification is information about important events which the service is required to send us by law.

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

Everyone we spoke with said they felt safe living at Flixton Manor. They said the staff were kind and caring. Staff had received training in safeguarding adults and knew the correct action to take if they witnessed or suspected abuse. Staff were confident that the registered manager would act on any concerns raised.

Assessments of people’s needs had been completed. However there were duplicated assessments and different assessment tools used for the same area of need resulted in different outcomes. Care plans and risk plans were identified from the assessments. People’s personal life history was not recorded. Staff did not have access to the care plans and relied on verbal information and their memory to know people’s needs and preferences. People and relatives were not involved in the formulation or review of the care plans.

All the people living at the home required two staff to support them to mobilise and with personal care. The staff on duty were busy throughout the day. They did not have time to sit and talk to people. Some staff did not talk to people when providing support for example when supporting a person to have a cup of tea.

The home did not have an activities organiser in place. The staff did not have time to arrange activities for people to be involved in. Appropriate music or films were not played, the television being on low volume throughout our inspe

We looked at a sample of seven people’s care plans and saw a pre-admission assessment had been carried out prior to admission. This was to ensure staff working at the home would be able to meet the persons care needs.

We saw people were offered hot and cold drinks throughout the day of our inspection. We spoke with people who lived at the home who told us: "They always ask if I would like tea or coffee." "We get lots to drink, they make sure of that." "When they bring a drink they ask if we would like a biscuit too."

We spoke with the relatives of two people who lived at the home. Comments included: "I don’t have any concerns at all I think X is quite happy here.” “I know they look after X." “There are no concerns about the staff they are all very nice.” “If I had any concerns about X’s safety I would speak to X.”

We looked at a sample of staff recruitment files and saw appropriate safety checks had been undertaken prior to new staff commencing employment. This included a Disclosure and Barring Scheme (DBS) check and a check against the Independent Safeguarding Authority (ISA) list to make sure applicants were not barred from working with vulnerable people.

We saw care plans and staff files were held electronically. Computer files were password protected and files were backed up on a daily basis to ensure information was kept safe.

We spoke with ten people using the service.

All the people spoken with said that staff respected their decisions in relation to choosing their preferred daily routines. Three people told us that their care and support was always provided in a dignified and private manner.

Seven of the ten people we spoke with told us they were happy with the standard of care and support they received. The staff were described as kind and caring, good listeners and good at what they did. The ten people were confident that their needs were being met.

Ten people told us that they felt safe living in the home. They confirmed that if they had any worries they would tell staff and were confident that staff would take appropriate action. One person said, "I feel confident that the staff would know what to do if I was at risk. They always listen and take what I say seriously".

Eight people said that staff responded in a timely manner to their requests for assistance. Two people said they sometimes had to wait for variable amounts of time for staff to assist them to the toilet. One person told us, "Yes I have to wait sometimes, because staff are so busy, but it usually gets done in the end".

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to look at the overall quality of the service. This inspection took place over two days on 29 August and 2 September 2014 and was unannounced.

Before the inspection we looked at information we held about this service, such as notifications and monitoring reports undertaken by the local authority.

During the inspection we spoke with three people who used the service, three visitors and a National Vocational Qualification (NVQ) Assessor. We also spoke with the provider and seven staff working in the home; the person in charge, two care staff, the clinical nurse lead, activities coordinator, the cook and the handyperson. We checked the environment for safety, hygiene and cleanliness and looked at policies, care plans and other records.

The registered manager was on holiday when we visited. After the inspection we asked them for feedback on the improvements they were making in relation to infection control. The registered manager provided the information requested.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe?

Care plans provided evidence of good risk management. For example, information in records provided evidence of staff taking prompt action to make referrals when they identified concerns relating to people's health and welfare.

Environmental risks had been assessed and the home's equipment had been subject to servicing and maintenance at regular intervals.

An application had been made for authorisation to restrict a person's liberty in order to protect them from accidental harm. The application was made appropriately under the Deprivation of Liberty Safeguards.

The registered manager had developed an action plan for making improvements to infection control systems in the home. This was in response to recommendations made following an infection control audit of the home in May 2014.

Seven staff told us they were confident that they had sufficient training and support to develop the knowledge and skills needed to safely care for and support people living in the home.

Auditing of the medication administration system had ensured that errors and omissions were identified and corrected.

Is the service effective?

The service was not always effective. Three relatives and a person living in the home confirmed that they had been consulted and contributed to developing care plans, although we found no evidence of this having been recorded in care plans.

Care plans did not contain evidence of capacity assessments to ensure that actions in care plans were being taken in the best interests of people who used this service. Consequently there was no evidence to show if decisions taken by staff complied with MCA guidance on best interest decision protocols.

Care plans and risk assessments had been kept up to date and people living in the home had been referred for professional advice when healthcare concerns had been identified.

Three relatives told us they were always made welcome when they visited and that there were no restrictions placed on visiting times. This enabled people living in the home to maintain and develop their relationships with family and friends.

Systems for dealing with complaints, suggestions and compliments made sure that the views of people using the service and their representatives were responded to by making improvements where appropriate.

People living in the home had access to a range of daily activities, which provided them with stimulation and interest.

Is the service caring?

Three relatives and a person living in the home confirmed that staff always treated people in a respectful and dignified manner. A relative said, "I visit most days and can honestly say that all the staff respect people’s privacy and dignity.”

During both our visits to this home we observed care and nursing staff use good observational skills to provide person-centred and compassionate care. A person living in the home told us, “It’s really good here. They look after us very well."

A senior member of staff told us they spent time sitting and talking to relatives when they visited, to ask their views on the quality of the service. This was confirmed in our conversation with three relatives.

During the midday meal we observed interactions between care staff, nurses and the people they cared for. We saw care staff use good observational skills to provide person-centred and compassionate care. Staff addressed people by their preferred titles and spoke with them in a quiet and calming manner to preserve their privacy and dignity.

Is the service responsive?

People living in the home had their needs assessed and their care plans showed how staff would provide care and support to meet their needs. The people we spoke with during our visit made positive comments about the way the service was provided. They said they were listened to and consulted about the care and support they received.

The registered manager and provider had taken responsive action to make improvements to the service. They gave us examples of the changes they had made in response to recommendations made by the NHS Infection Control Nurse and local authority contract monitoring. This demonstrated that the provider was responding by making improvements to the quality of the service being provided.

Is the service well-led?

The registered manager had implemented quality assurance processes to protect people living in the home from accidental injury, medication errors and the risks associated with providing care and treatment.

The people we spoke with during our visit told us the home was managed well. A visiting National Vocational Qualification (NVQ) assessor said, "This is one of the better homes. The staff are well trained and the home is well run. Staff receive good support to achieve their NVQ qualifications."

Staff working in the home told us, "The manager is fair, approachable and firm. Things get done and it's a really good home to work in. We work well as a team."