We undertook an unannounced focused inspection of Lindridge on 23 October 2018. This inspection was done to check that improvements to meet legal requirements planned by the provider after our 22 May 2018 inspection had been made. The team inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? This is because the service was not meeting some legal requirements.

This service was selected to be part of our national review, looking at the quality of oral health care support for people living in care homes. The inspection team included a dental inspector who looked in detail at how well the service supported people with their oral health. This includes support with oral hygiene and access to dentists. We will publish our national report of our findings and recommendations in 2019.

When we completed our previous inspection on 22 May 2018 we found the provider had failed to ensure that people were receiving their medicines safely. A warning notice was issued for a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there was a lack of management oversight and governance which meant that the service had failed to sustain improvements, risks had not always been identified and managed and records were not always accurate and complete. In July 2018 the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of regulations.

We undertook this focused inspection to check that the provider had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lindridge on our website at www.cqc.org.uk.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection. The overall rating has improved to Good.

Lindridge 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. Lindridge accommodates up to 75 people across three units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. On the day of this inspection there were 40 people living at the home.

Lindridge has 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.

Improvements had been made in systems for managing the administration of people’s medicines. People were receiving the medicines they needed safely and systems for ordering medicines had improved so that people had access to their prescribed medicines when they needed them. This meant that the provider had met the requirements of the warning notice.

Some new systems had been introduced but not all staff were confident and familiar with the new systems. This meant that improvements were not yet fully embedded and sustained. We identified this as an area of practice that needs to improve to ensure positive changes are sustained.

Risks to people were assessed and managed effectively. Care plans provided staff with

Lindridge 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. Lindridge is a large residential care home providing care and support to up to 75 people. The home is divided into different areas, providing a number of short term beds for people leaving hospital, as well as a specialist unit in two areas of the home for people who were living with dementia. This inspection took place on 22 and 23 May 2018 when there were 54 people living at the home.

The home 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.

At the last inspection on 22 June 2017 we found one breach of the Regulations and some areas of practice that needed improvement. 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 question to at least good. At this inspection, on 22 and 23 May 2018, we found that there had been improvements and the previous breach had been addressed. However, we found some other areas of practice that continued to require improvement.

People were not always supported to receive their medicines when they needed them. Systems had not always ensured that there were sufficient medicines in stock to meet people’s needs. Records were not always accurate and complete. This meant that the registered manager could not be assured that people were receiving their medicines as prescribed. This was a continued breach of the regulations.

Management systems and processes were not always effective in identifying shortfalls in practice. Governance arrangements were not clear in all areas of the home. Improvements had not been sustained and embedded within practice. This was a breach of the regulations.

People told us they were happy living at Lindridge. One person said, “It’s a very pleasant atmosphere here.” Another person told us, “It’s fantastic. I feel very safe because I am so well looked after.” Risk assessments and care plans were in place to guide staff in how to support people safely. There were enough staff on duty to meet people’s needs. Staff demonstrated a clear understanding of safeguarding and whistleblowing policies. Incidents and accidents were monitored and there were robust infection control procedures in place.

Staff received the training and support they needed to be effective in their roles. Assessments were in place to identify people’s needs and choices. Staff understood their responsibilities with regard to gaining consent from people for their care and support. Staff ensured that people had access to the health care services they needed. People were supported to have enough to eat and drink and risks associated with nutrition and hydration were managed effectively. People spoke highly of the food and drink on offer, one person said, “It’s very good, it’s tasty and hot.”

People and their relatives spoke highly of the caring nature of the staff. Their comments included, “The staff a very kind and gentle with me,” and, “We are blessed to have kind staff here.” Staff supported people to remain as independent as possible. People were treated with dignity and their views were respected. People and their families were involved in making decisions about the care provided. One person told us, “I’m very satisfied that I was able to discuss my care plan.” Staff maintained people’s confidentiality and supported people’s privacy.

Staff knew people well and people told us their care was person-centred. One person said, “My care has been tailored

Lindridge is a large residential care home providing care and support to up to 75 people. The home is divided into different areas, providing a number of short term beds for people leaving hospital, as well as a specialist dementia unit in two areas of the home. This inspection took place on 22 June 2017 when there were 61 people living at the home. At the last inspection on 30 March 2016 we found one breach of the Regulations and some areas of practice that required improvement. At this inspection, on 22 June 2017, we found that there had been improvements and the previous breach had been addressed. However we found some other areas of practice that required improvement.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been absent from the home since January 2017 and the home was being managed by the deputy manager who was present throughout the inspection.

At the last inspection on 30 March 2016 there was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was due to concerns about the proper and safe management of medicines. At this inspection on 22 June 2017 the provider had made improvements and had addressed the previous breach of regulation.

Some risks to people were not being consistently managed. Some people had enteral feeding tubes and risks associated with maintaining the feeding tubes were not being managed. This is an area of practice that requires improvement. We brought this to the attention of the deputy manager and immediate steps were taken to address this issue.

Some people were receiving their medicines covertly but records did not always show that this decision had been taken in line with the Mental Capacity Act 2005. This is an area of practice that needs improvement.

There were systems and processes in place to monitor quality but not all systems were working effectively. This meant that some shortfalls had not been identified and acted upon and some records were not complete and accurate. This is an area of practice that needs to improve.

People and their relatives told us that they were happy with the care provided at Lindridge and they felt safe. One person said, “I’m a happy bunny, of course there are ups and downs but I like it mainly, it’s my home.” A relative told us, “When I leave here, I don’t worry.” There were enough staff to keep people safe and recruitment processes were robust. Risks to people had been assessed and plans were in place to guide staff in how to keep people safe. Incidents and accidents were monitored and analysed to reduce risks of further similar events. Staff supported people to access health and care services when they needed them. One person told us, “If ever I’m ill, like in January I was ill, they got me down to the hospital and they responded quickly.”

Staff received training and support and were confident in their roles. Communication was good and staff had a firm understanding of their responsibilities. The environment of the home had been adapted and designed to meet people’s individual needs. A number of dementia friendly features had been added to help people to orientate themselves and to reduce anxiety. People who had mobility needs were able to move around the building and access the garden independently.

People had developed positive relationships with staff and spoke highly of their caring nature. One person said, “The staff are lovely, really respectful, patient and caring.” Staff knew people well and encouraged them to make decisions about their care and support. One staff member said, “We try and support people to remain in charge of their care

Lindridge is a large residential care home providing care and support for up to 75 people. Since the last inspection in May 2014 the home has been through a period of considerable growth and change with an increase in the number of people that can be accommodated from 25 previously to 75. This has involved the redesign, extension and refurbishment of the building to accommodate a number of short term beds for people leaving hospital, as well as a specialist dementia unit and a unit for people with behaviour that can challenge. On the day of the inspection the specialist unit for people who have behaviour that can challenge was not yet open and there were 48 people living at Lindridge.

The home has 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.

Not all medication practices ensured that medicines were managed safely. Medicines that required refrigeration were not always stored within the required temperature range and there was a recording omission in the MAR chart for one person. Pain assessment charts held for each person stated the pain relieving medicines they had been prescribed. Some entries on these did not state a minimal interval between doses, or a maximum daily dose. These instructions are needed to ensure the safe administration of medicines.

We checked whether staff were working within the principles of the MCA and whether conditions or authorisations to deprive a person of their liberty were being met. None of the staff members that we spoke with could tell us about the implications of DoLS for the people they were supporting. We identified this as an area of practice that needs to improve. Staff were able to demonstrate a good understanding of the MCA including the nature and types of consents, people’s right to take risks and the necessity to act in people’s best interests when required. However they were not consistent in their approach to undertaking Best Interest decisions.

People were not always consistently supported and monitored where nutritional risks had been identified. One person had been assessed by a Speech and Language Therapist (SALT) due to difficulties with swallowing however staff were not aware of the identified risks for this person or the SALT guidance regarding positioning, monitoring and advice stating that the person should be supervised when eating. This meant that identified risks associated with eating and drinking were not being appropriately managed.

People told us they felt safe living at Lindridge, one person said, “I feel secure here, the staff know how to care for me and the other people here.” Risks to individuals were identified and managed including environmental risks and risks of infection. Staff were knowledgeable about the correct procedures to follow should they suspect abuse and there were robust recruitment procedures in place to ensure that staff were suitable and safe to work in the care sector. People told us that there were enough staff on duty to care for them, one person said “Staff are still busy but they make time, I have never felt rushed by anyone.” Throughout the inspection we observed that staff were spending time with people, providing care but also just chatting and keeping people company. Staff rotas showed that staffing levels were maintained and we saw evidence that recruitment to vacant posts was in progress.

People told us that they felt well cared for, that staff were kind and their views were valued, saying “They do treat me with respect and maintain my dignity, they shut the door and pull the curtains before attending to me.” Throughout the inspection we saw positive interactions between staff and people with many examples

Our inspection team was made up of one inspector. We answered our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary describes what people using the service, their relatives, visitors and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw care plans that reflected issues identified in the assessment. These were sufficiently detailed to allow nursing and care staff to deliver safe and responsive care. A care worker said, “The care plans are drawn up by the nursing staff and allow us to work confidently with that person.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

People were cared for in a clean, hygienic environment. The service had systems in place designed to assess the risk of, and to prevent, detect and control the spread of infection.

During our unannounced visit, we observed there were sufficient care staff to meet people's needs. We checked the rotas and saw that staffing levels were well maintained.

Is the service effective?

We saw that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We saw that people or their representatives had been involved in their care assessments and reviews.

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. One person who used the service told us, “The staff here take care of all our needs. We are well looked after.” Staff had received training to meet the needs of the people receiving care.

Is the service caring?

People were supported by committed and attentive staff. We saw that care staff were patient and empathetic when supporting people. The relative of one person told us, “I cannot fault the care given to [My relative] at Lindridge. They couldn’t be in better hands. The kindness and efficiency of the care givers is amazing.”

Is the service responsive?

People’s needs were continually assessed. Records confirmed people’s preferences, interests, aspirations and diverse needs had been recorded and care and treatment had been provided in accordance with people’s wishes. One person told us, “I really can’t fault the care. [My relative] wouldn’t be here if I didn’t think he was well looked after. When [my relative] moved in they made so many changes to suit his needs. They chopped and changed the location of his bed, provided a special mattress.”

Is the service well-led?

Staff had a good understanding of the ethos of Lindridge and its commitment to providing personalised individual care. Quality assurance processes were in place to support this. People told us they were asked for their feedback on the service they received and they confirmed they had felt listened to. Systems were in place to help the service develop and learn.

On the day of our inspection there were 23 people living in the home. We visited each of the rooms and met with seven people who used the service. We spoke with three relatives, three members of staff, the registered manager and representatives from the Trust's management team.

People told us they felt happy and safe in the home. Everyone remarked on the kindness of the staff. We were told that people felt confident that any concerns were always quickly addressed. One person told us “the staff are "Kindness itself, nothing is too much trouble.”

People told us that staff understood their needs and provided appropriate care and support. We were told that staff were responsive when people asked for assistance and quickly dealt with any issues. We found that the home enabled people to lead fulfilling lives by listening and supporting people to reach their potential. One person told us "I have a brilliant quality of life - it couldn't be better."

We found care was recorded appropriately, with potential risks to people’s safety monitored, assessed and updated in a timely manner. We saw that the home provided high quality training and support to staff which was reflected by the people who used the service and their relatives praising the knowledge and expertise of the staff in caring for them. We found there were robust systems in place to continuously monitor the quality of serve offered.