This inspection took place on 27 and 31 July 2017 and was unannounced. This meant the staff and provider did not know we would be visiting.

Lindisfarne Hartlepool provides care and accommodation for up to 54 people, some of whom have a dementia type illness. On the day of our inspection there were 51 people using the service.

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 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.

Lindisfarne Hartlepool was last inspected by CQC on 28 June 2016 and was rated Requires improvement overall. No breaches of Regulations were identified at the previous inspection, however, actions were required to improve the service.

Accidents and incidents were appropriately recorded and analysed monthly to identify any trends. Risk assessments were in place for people who used the service and described potential risks and the safeguards in place to mitigate these risks.

At the previous inspection it was identified that not all safeguarding records were complete. At this inspection we found records had been appropriately completed, the manager understood their responsibilities with regard to safeguarding and staff had been trained in safeguarding vulnerable adults.

Medicines were stored safely and securely, and procedures were in place to ensure people received medicines as prescribed.

The home was clean, spacious and suitable for the people who used the service, and appropriate health and safety checks had been carried out.

There were sufficient numbers of staff on duty in order to meet the needs of people who used the service. The provider had an effective recruitment and selection procedure in place and carried out relevant vetting checks when they employed staff. Staff were suitably trained and training was arranged for any due or overdue refresher training. Staff received regular supervisions and appraisals.

The provider was working within the principles of the Mental Capacity Act 2005 (MCA) and was following legal requirements in respect of the Deprivation of Liberty Safeguards (DoLS).

People were protected from the risk of poor nutrition and staff were aware of people’s nutritional needs. Care records contained evidence of people being supported during visits to and from external health care specialists.

People who used the service and family members were complimentary about the standard of care at Lindisfarne Hartlepool. Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible.

People’s needs were assessed before they started using the service and an admission checklist was completed. At the previous inspection some inconsistencies were identified in people’s care records. At this inspection we found care records were accurately completed, up to date, and regularly reviewed and evaluated. Care plans were written in a person-centred way. Person-centred is about ensuring the person is at the centre of any care or support plans and their individual wishes, needs and choices are taken into account.

Activities were arranged for people who used the service based on their likes and interests and to help meet their social needs, and the service had good links with the local community.

People who used the service and family members were aware of how to make a complaint however did not have any complaints to make.

At the previous inspection it was identified that the quality assurance process was, “work in progress”. At this inspection we found the provider had an effective quality assurance process in place. Staff said they felt supported by the manager and were comfortable raising any concerns. People who used the servi

Lindisfarne Hartlepool is a nursing and residential home, although at the time of the inspection it was not providing nursing care. It is registered to provide care for 54 people. At the time of our inspection there were 46 people living at Lindisfarne Hartlepool.

At the last inspection of the home in February 2016, we asked the provider to take action to make improvements. This was because we found the provider had breached a number of regulations.

We found the provider had not ensured staff received appropriate training and development to enable them to carry out the duties they were employed to perform. The registered manager failed to identify and take appropriate action in regard to safeguarding concerns. The provider had not ensured equipment was in place to ensure the safety of people who used the service and to meet their needs. Care records did not reflect people’s needs and preferences. People were not always treated with dignity and respect. People’s confidential information was not held securely. We also found that the provider did not have effective quality assurance processes to monitor the quality and safety of the service provided and to ensure that people received appropriate care and support.

This inspection took place on 28 June 2016 and was unannounced. This meant the provider did not know we would be visiting.

A registered manager was in place at the time of our inspection. 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.

We found the provider had made a number of improvements since the last inspection. We found the provider had reported safeguarding issues to the relevant local authorities and had notified CQC of these. However, we noted in one of the seven referrals there was no record of any investigation into allegations made by a person who used the service.

There were enough staff on duty to support the people who lived there. The provider carried out checks to make sure only suitable staff were employed. Staff now had suitable training and supervision to carry out their roles.

Potential risks to people and the premises were assessed and managed.

The provider followed the principles of the Mental Capacity Act 2005 (MCA). This meant safeguards were in place for people who did not have capacity to make some significant decisions.

There had been improvements to the dining arrangements and this supported people with their nutritional needs.

Quality assurance processes used to monitor the quality and safety of the home had been completed and the registered manager had used this information to drive improvement.

A full-time activities coordinator had been employed and the activities room was utilised daily.

Whilst improvements had been made there were still areas for development including people’s care records and the protection of people’s confidential information. The registered manager recognised that the consistency and quality of care records was an area that required further work.

Medicines records we viewed were complete and up to date. This included records for the receipt, return and administration of medicines.

Relatives and people told us staff were kind and caring. Staff had a sound knowledge of the people they supported, their likes and dislikes.

Relatives were made welcome and were involved in their relatives care planning.

The home worked with external professionals to support and maintain people’s health. We saw evidence in care plans of cooperation between care staff and healthcare professionals including, occupational therapists, podiatrists and GPs.

The provider sought feedback from people, relatives and staff in order to develop and improve the home.

Lindisfarne Hartlepool is a nursing and residential home, although at the time of the inspection it was not providing nursing care. It is registered to provide care for 54 people. At the time of our inspection there were 52 people living at Lindisfarne Hartlepool.

The inspection took place on 24, 26 and 29 February 2016 and was unannounced on the first day. We last inspected the home on 22 July 2015. At that inspection we found training records were not up to date and staff had not received regular supervisions and appraisals. The registered provider advised us after the initial inspection that all these concerns had been addressed.

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.

During this inspection we found the provider had breached a number of regulations. The provider had not ensured that staff received appropriate training and development to enable them to carry out the duties they were employed to perform. The registered manager failed to identify and take appropriate action in regard to safeguarding concerns. The provider had not ensured equipment was in place to ensure the safety of people who used the service and to meet their needs. Care records did not reflect people’s needs and preferences. People were not always treated with dignity and respect. People’s confidential information was not held securely. We also found that the provider did not have effective quality assurance processes to monitor the quality and safety of the service provided and to ensure that people received appropriate care and support.

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

The provider operated a comprehensive recruitment system. All appropriate checks were conducted prior to an applicant’s start of employment.

Accidents and incidents were not analysed to identify any patterns or trends.

The home did not have any form of evacuation equipment and staff did not have the appropriate training to safely evacuate people in the event of an emergency.

Two bathrooms were used as a sluice, whilst also being used as a bathroom with a risk of cross- contamination.

Staffing levels were calculated by Head Office and took into account people’s needs.

People did not receive sufficient engagement or stimulation. No specific activities were available for people living with dementia.

When people first moved into the home, the least restrictive options and authorisations for deprivation of people’s liberty was not always considered in a timely manner.

The written menus on display did not reflect what was on offer that day. The registered manager told us pictorial menus were available and they repeatedly reminded staff to use them.

People were woken during the night to be given fluids. Care plans did not indicate a clinical reason for either being on food and fluid charts or why fluids were being offered repeatedly during the night.

The provider involved external health professionals when required. For example, the falls team, dietitian, tissue viability nurse and respiratory nurse.

Complaints were not fully investigated and responded to in line with the provider’s policy.

26 staff members had not completed dementia awareness training.

The registered manager advised they conducted a daily walkabout. However this had not detected the issues we identified during our inspection and they were not recorded.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘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 regis

This inspection took place on 22 July 2015 and was unannounced. This meant the provider did not know we would be visiting. We last inspected the service in January 2014 and found the provider was meeting all the legal requirements we inspected against.

Lindisfarne Hartlepool is registered to provide accommodation and personal care for up to 54 people, including some people who were living with dementia. At the time of our inspection there were 45 people using the service.

No registered manager was in place at the time of our inspection. The manager advised us they had applied to become a registered manager. 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.

Training records were not up to date and staff did not receive regular supervisions and appraisals. This meant that staff were not properly supported to provide care to people who used the service. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

People we spoke with told us they felt safe. One person said, "They look after me well I feel like I am one of the staff.” One family member said, "Yes [my relative] is safe here, [my relative] still has some independence."

The provider had a safeguarding policy and procedure in place which staff were fully aware of.

We saw the provider had alerted the local authority to one safeguarding incident in June 2015. All appropriate action had been taken and staff had responded accordingly.

Medicines records were up to date and accurate. This included records for the receipt, return, administration and disposal of medicines.

We saw the home had produced an emergency evacuation plan for everyone living at the home. We noted the emergency evacuation plan was updated regularly and detailed the support each person required.

We saw the provider adhered to its recruitment policy. Staff recruitment files contained two written references, one of which was the previous employer and a disclosure and barring service check (DBS).

Where required people were supported to get assistance from external professionals. We saw from records that GP’s, district nurses and occupational therapists were regularly involved in people’s care.

People we spoke with told us they were treated with dignity and respect. We noted when people were receiving personal care in their rooms the door was closed and staff knocked before entering. One person told us, "They treat me very well.” And another said, “Yes they are very nice people.”

Family members told us they were involved in the care and support their family member received. We saw documentation in people’s care records confirming their involvement.

We found people did not receive sufficient engagement or stimulation. We observed people spent a long period of time sat in the lounge areas; some remained in the same seat for their lunch and dinner. We have made a recommendation about this.

We noted that care plans were thorough and covered a variety of topics. We also saw that where required the care plans had been linked to show how one healthcare need may impact on others. For example, we saw that one person had a care plan in place for communication.

People told us they would be confident raising concerns. One person said, “I would go straight down and tell them off, I would let them know I was not satisfied.” One family member said, “I visit two to three times a week, at all different times and I have no concerns. If I did I would be happy to staff to the staff though, they are all lovely.”

We noted the home completed regular health and safety audits. However, these were not always effective. We found they had picked up a number of concerns with some of the emergency lighting not working but this had not been rectified.

Staff worked well as a team supporting each other when required. Staff told us it was a happy place to work. One new starter told us, “I feel part of the team and everyone is so helpful.”

We found the information gathered from complaints, accidents and incidents and general audits was not used to drive continuous improvement. The provider had recently introduced a quality assurance system we were shown one months completed audit, no other audits were available before that date.

The provider gave people who used the service and their family members the opportunity to give their views about the service. We noted surveys, questionnaires and meetings were used to capture people’s and relative’s opinions.

Staff had an understanding of the Mental Capacity Act 2005 and their responsibilities in relation to the Act. There was documentation in place to show that capacity assessments had been carried out and best interest decisions were recorded. Staff however needed support to apply the Act in practice.

People who used the service were able to access sufficient food and drinks that were nutritious and appetising. People were weighed regularly and action taken when concerns were identified.

We found that when people received care from a number of different services, there was evidence that they communicated with each other. Advice given to staff at Lindisfarne was recorded in people’s care plans and followed.

We found that there were sufficient staff employed and deployed by the service to make sure that people’s needs were met in a timely manner. Staff had the skills and knowledge to meet people’s needs.

We found that the provider had taken action to improve the systems in place for ordering, storing and administering medication. This meant that people received their medication correctly and safely.

The provider had organised for staff to attend a number of different training sessions to enable them to deliver care safely and appropriately. Although some staff were still in need of refresher mandatory training this had been organised for them to attend within the coming months. People who used the service were care for by staff who were supported to gain the skills and knowledge to care for them safely.

We found that there were systems in place to assess the quality of care people received and a recent satisfaction survey had been carried out.

The records held by the service were stored securely and were easily accessible to staff. Care records were on the whole up to date and accurate and contained sufficient information to ensure that people who used the service received the care and support they needed safely.

This inspection was completed as a follow up to our previous visit in June 2013. At this inspection we focused on whether the provider had achieved compliance with one of the warning notices and the administration of medication, which was also noted to be problematic at the last inspection. The particular warning notice we checked was related to ensuring the care and welfare of people using the service was appropriate.

Since the last inspection the provider has stopped offering nursing care at the home and now looks after people who require residential care.

During our inspection, we spoke with two relatives; four people who used the service and visiting healthcare professionals. Most people who used the service experienced difficulty communicating their views and opinions so we also spent time observing how staff worked with individuals.

The relatives and people who used the service told us that they were happy with the standard of care offered in the home. People said “The staff are very friendly and make me feel at home” and “It is a nice place to be”. The visiting health professionals we spoke with felt that in recent weeks the service had greatly improved.

We found that the concerns raised about the home’s ability to meet more complex needs of people had been resolved. However, although improvements had been made around how staff managed people’s medicines we found that staff still could not demonstrate this was always administered safely.

The visit took place because we were following up concerns raised at the last inspection in February 2012. Therefore, during this visit, we focussed on those specific areas raised in the last inspection. These included concerns about the moving and handling of people; the experiences of people whose behaviours can challenge; the safe handling of medication; and, the arrangements in place to ensure people were not at risk of financial abuse or theft.

We used a number of methods to help us understand the experiences of people using the service. Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people’s experiences of living in the home and their interactions with each other and the staff. We call this the ‘Short Observational Framework for Inspection' (SOFI).

We observed staff using hoists to move people. We saw that staff explained what they were doing before they did it, they gave encouragement and verbal support to the person to make sure their level of anxiety was minimised. We saw people were moved in a safe way that minimised the risk of injury or accident.

We saw the staff gave people gentle encouragement to assist them to receive adequate nutrition and hydration. Staff offered people food a number of times over the lunch period to encourage them to eat and drink enough to keep them healthy and promote their wellbeing. When people did not eat the food available, they offered them choice of different foods to encourage them to eat. We also saw staff orientate people in time and space to remind them it was a meal time. Where people had difficulty eating staff provided assistance, but also assisted them to eat independently to ensure they could maintain autonomy and their own life skills.

We found that staff were attentive to people, and treated individuals with respect.

We saw that staff encouraged people to be involved in preparations for the Jubilee weekend celebrations. The home was decorated with flags and people were encouraged to fill jars with sweets to celebrate the Queen's Jubilee.

We found that staff had supported people using the service to be well presented and clean. During the day, people were supported to get their hair done by a visiting hairdresser.

We chatted to six people using the service during our inspection. Although people were not able to share detailed descriptions of their experience within the home, people said they thought the home was good and the staff were nice.

We also gathered evidence of people's experiences of the service by reviewing the complaints log kept within the home. We also viewed responses to a questionnaire sent out by the home to people's families, friends and representatives. Overall, the questionnaires were positive about the home and the care delivered by staff. However, a few of these questionnaires noted concerns about the lack of a permanent manager.

The visit took place because we were concerned about a number of incidents that had taken place at Lindisfarne Hartlepool between January and February 2012. This included a number of alleged thefts of money and valuables from people using the service, and concerns about care and welfare of people using the service. We were informed by the manager and relatives that the police are investigating the thefts. We are not able to investigate criminal offences like theft but can focus our inspection around how the home makes sure appropriate safeguards are place and that people’s health and well-being needs are met.

During our inspection visit, we spoke with three people who use the service and the relatives of two people. The people we spoke with were positive about the service, and liked the home.

One relative told us "I'm very happy with the care here. I moved my relative from another home, as she wasn't happy. She seems settled here." They also said, "The home helps them with their medication. They did lose a bit of weight when they came in, but they are fine now. When they have had an infection, they picked it up and acted on the symptoms."

Another resident we spoke with was unhappy with the response from the service to a complaint she had made, as it would be 28 days before the service would formally respond. However, they did feel like the care for their relative had improved since they had made their complaint.

The visit took place because we were following up concerns raised at the last inspection in July 2011. Therefore when talking with people we concentrated on those specific areas raised in the last inspection. We spoke to ten people who used the service and five relatives. People were very complimentary about the staff and manager and said ''the staff are excellent and the care is very good, which means I no longer worry about my relative'', ''He is a good lad, if he sees something needs doing he just gets on with it''. Others said ''The care is brilliant'' and ''The care is excellent, I have no complaints''.

Some people on the residential unit told us that they had raised concerns about the behaviour of others and how these people needs were not being met. The manager agreed with this and was taking action to resolve the issues. All of the people did feel staff were skilled. People felt that within each unit, staff knew how to care for the people the unit was designed to accept.

A proportion of the people living at the home had marked problems with their memory and found it difficult to think about recent events or at times to hold a conversation. Therefore, we used a specific way of observing care to help to understand the experience of people who could not talk with us. This involved spending a substantial part of the visit observing a group of people to see how they occupied their time, appeared to feel and how staff engaged with them.

From our observation, staff were constantly working in ways that supported the people and they made sure individuals could follow what was being said; included people in

conversations; and approached people in a gentle and caring manner. If people were

experiencing distress, staff quickly went to the person and offered comfort. Staff have not recently received training in dementia care, but did interact with people in a very caring and respectful manner.

The people we spoke to said that they are able to make choices about how they spend their day and choose either to stay in their own room or go to the day room.

One person we spoke to said "I like to stay in my own room and watch the television."

We spoke to five people who use the service at Lindisfarne Hartlepool and three relatives. All the people we spoke to said they were aware of activities that took place within the home and also out in the community and said they could join in if they wish. The people we spoke to and their family members said they didn’t feel involved in the planning of their care or the decisions made.

All the people we spoke to were happy with the cleanliness in the home and described their rooms as clean and comfortable.

The people we spoke to who live on the ground floor said they were happy with the care they received; one person said “the girls are good they help me when I need it"

Overall the people we spoke to who lived on the first floor felt that the staff were busy. For example one person we spoke to said

"The staff are nice but they are so busy, they answer the buzzer if I need them, it can take about 15 minutes"

A family member said “when I ask staff for an update on how mum has been they say I don’t know I wasn't on this floor yesterday"

During our inspection, we spoke with some relatives and people who used the service. They told us they were mostly happy with the care and treatment people received.

We spoke with visiting health professionals who told us they had concerns about the quality of care and treatment delivered by the service.

We identified a number of concerns about if the service was able to meet more complex needs of people. We found improvements needed to be made quickly to improve the safety of people who used the service. However we did find that people were clean, warm and comfortable and on the whole, their nutrition needs met.

We had concerns about the care and treatment some people received, how decisions were made for people who may have lacked capacity and how people who were at risk of malnutrition were being managed. We found that staff sometimes misinterpreted or did not follow guidance from external health professionals and did not always administer medication safely.

We had concerns with the way staffing levels were calculated and the checks made to ensure staff had the skills and knowledge to meet all of the complex needs of people. Staff were not up to date with mandatory and other specific training to meet people’s needs and this had not been made available to them by the provider.

There had been no quality assurance checks carried out by the service for over six months.

The records held by the service were not fit for purpose and improvements were needed.