This inspection took place on 22 November 2018 and was unannounced. Our last inspection was in July 2018 when the service was rated Good. There had been two changes of management since our last inspection and we brought this inspection forward due to concerns raised through safeguarding. This inspection identified five breaches of the legal requirements relating to staffing, risks, dignity, care planning, activities, training, complaints and governance. You can see what action we told the provider to take at the back of this report.

Linwood 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.

Linwood accommodates up to 67 people in one purpose built building. The service provides residential care to older people with physical disabilities and long term medical conditions. They also provide support to people living with dementia. At the time of our visit, there were 54 people living at the home.

There was not a registered manager in post. The manager had been recently recruited and was in the process of registering with CQC. 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.

People told us that the staff who supported them were not always kind or caring. We heard examples of staff being rushed, failing to interact with people or not being kind. We observed instances where staff did not consider how best to protect people’s dignity and where people had made specific requests, they had not been responded to. There was a lack of interaction and staff did not always respond to changes in people’s wellbeing and circumstances.

There was not a positive culture at the service. Staff felt unsupported by management and recent changes had been implemented in a way that had impacted upon people negatively. People, relatives and staff told us that there were insufficient numbers of staff deployed to meet people’s needs. Where this had been raised repeatedly, it had not been addressed and people’s experience had not changed. The information about people’s needs that was used to calculate staffing numbers was not accurate.

People’s concerns were not responded to and records of complaints were not accurate. There were a variety of checks and audits taking place, but they did not identify shortfalls in risk management and record keeping that this inspection identified. Staff were not receiving regular one to one support and training to support them in their roles. There was a lack of systems to encourage communication between staff.

Risks to people were not always safely monitored. We identified inconsistencies and shortfalls in charts to monitor risks and where plans were made to reduce risks, we identified instances where the measures were not being followed. People’s care plans sometimes lacked information about how they liked to receive their care, their preferences and needs relating to medical conditions. The records relating to people’s healthcare appointments were inconsistent and lacked accuracy.

People told us they sometimes felt bored and whilst there was a programme of activities in place, we identified missed opportunities to involve people. People’s wishes and preferences regarding end of life care were not always documented and where people had specific clinical needs, records relating to these were not clear for staff.

Staff understood how to respond to safeguarding concerns and the provider kept a record of any incidents or accidents which they monitored. The home environment was suited to people’s mobility needs and there was a plan to improve comm

The inspection took place on 09 August 2017 and was unannounced.

Linwood is a residential care home providing support to up to 67 older people across three floors. At the time of our inspection, there were 59 people living at the home, many of whom were living with dementia.

Our last inspection was in April 2016 where we found breaches of regulations. We found that risks to people were not being managed effectively and the care that people received was not always person-centred. At this inspection, the provider had made the necessary improvements to meet the requirements of the regulations.

There was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The manager had recently left and the provider was in the process of recruiting a new manager.

Risks to people were assessed and staff identified plans to keep people safe. The provider carried out checks to ensure that the environment was safe for people. There were systems and plans in place to keep people safe in the event of an emergency.

Where any accidents or incidents occurred, staff took action to prevent the same incident happening again. Staff understood their roles in safeguarding people from abuse and took appropriate action when required. People’s legal rights were protected because staff followed the Mental Capacity Act (2005).

The provider carried out appropriate checks to ensure that staff were suitable for their roles. There were sufficient numbers of staff present to meet people’s needs. We did note an inconsistency in care on one unit and one time of day. We recommended that the provider reviews their staff deployment in this area.

People’s care plans were person centred and reflected their needs and interests. People’s records were up to date, except in two instances where recent information had not been added to people’s care plans. We recommended that the provider reviews their systems for updating records.

People had access to healthcare when they needed it. Where healthcare professionals were involved, staff worked alongside them to meet people’s needs. People’s medicines were managed and administered safely by trained staff.

Staff had the training that they needed to carry out their roles. Staff told us that they felt supported and had regular supervision meetings with their line managers. Staff were involved in the running of the home through regular meetings and the provider had effective communication systems in place.

We observed a number of caring interactions throughout the inspection. People were supported by staff that knew them well and promoted their independence. Staff respected people’s privacy and dignity when providing care to them. People were offered choices and staff involved people in their care.

People were given food in line with their preferences and dietary requirements. Important information on people’s diets was in their care records. There was a range of activities taking place at the home and the home and garden environment provided people with areas where they could spend time.

People’s feedback was regularly sought by the provider. Where people raised complaints, these were responded to appropriately. The provider carried out regular checks to ensure the quality of the care that people received. Where any areas for improvement were identified, these were actioned by staff.

Linwood is a care home that provides residential care for a maximum of 67 older people who may also be living with a dementia type illness. The home is divided into six units across three floors. At the time of our inspection, there were 61 people living in the home.

We previously carried out an unannounced comprehensive inspection of this service on 11 June 2015. At that inspection a number of breaches of legal requirements were found. As result the service was rated inadequate overall and the provider was placed into special measures by CQC. In addition to making a number of legal requirement actions for the service to improve, we also issued two Warning Notices which required the provider to take immediate action in relation to staffing levels and the governance of the home. We undertook a further focussed inspection on 28 September 2015 which found that the provider had taken immediate action to rectify the serious concerns we raised about the service in June 2015. Improvements to staffing levels and the way the home was being managed meant that the provider had complied with the Warning Notices we had issued. We also saw that work was continuing to address the other breaches in legal requirements, although we also identified some new breaches in respect of the way medicines were managed, recruitment processes and the standard of record keeping within the service.

Since our last inspection we have continued to engage with the provider. We asked the provider to submit regular action plans that updated us about the steps they had taken to improve the service. This inspection confirmed that the provider had taken the action they told us they had. Significant improvements to the way the home was being managed meant that the provider had complied with the requirements we had previously issued and we have now taken Linwood out of Special Measures.

The service did not have a registered manager in post. 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. A new manager had been appointed in February 2016 and was in the process of registering with the CQC.

Since our last inspection, the service had experienced a period of considerable change. Whilst it was evident that the quality of care had improved, the new leadership of the home now needed to be embedded and sustained. In particular, we highlighted that communication was not always effective across the service and the manager required greater support from those working below him to ensure changes were delivered effectively and consistently across the service.

Each person had a plan of care, however risks to people had not always been appropriately assessed and managed. For example, one person who had recently moved to Linwood had not been properly assessed either prior or post admission. As such staff were supporting this person with only limited information about their needs. We also found that plans in place to support staff to evacuate people in the event of an emergency did not reflect people’s individual needs.

Whilst staff had a greater understanding about the need to involve people in decisions about their care and gain consent, they lacked a good understanding of the Deprivation of Liberty Safeguards. As a consequence people were not always cared for in the least restrictive way.

We found that people were supported to have better choice and control over their care, but that their social needs were not always met. Whilst the service had a programme of activities available, this did not always match people’s own expectations and provide them with sufficient opportunities to engage in activities that were meaningful to them. Staffing levels had improved and were now sufficient

We carried out an unannounced comprehensive inspection of this service on 11 June 2015. At that inspection a number of breaches of legal requirements were found. As result the service was rated inadequate overall and this provider was placed into special measures by CQC. As part of this decision, we met with the provider to discuss our concerns. We also issued two Warning Notices which required the provider to take immediate action in relation to staffing levels and the governance of the home. We undertook this focused inspection to check that this action had been taken. This report only covers our findings in relation to whether the service is Safe and Well Led. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Linwood on our website at www.cqc.org.uk . The service remains in Special Measures and we will be re-inspecting to make sure that improvements have been made and are sustained.

This inspection found that the provider had taken immediate action to rectify the serious concerns we raised about the service in June 2015. Improvements to staffing levels and the way the home was being managed meant that the provider had complied with the Warning Notices we had issued. We also saw that work was continuing to address the other breaches in legal requirements, although we also identified some new breaches. CQC is therefore now considering the appropriate regulatory response to monitoring this provider going forward.

Linwood is a care home that provides personal care for up to 67 older people, some of whom are living with dementia. The home is divided into six units across three floors. Each unit has its own communal space. A large garden is located to the rear of the home.

This inspection took place on 28 September 2015 and was unannounced. There were 61 people accommodated at the home, one of whom was in hospital at the time of our visit.

The home had 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.’ Since our last inspection, the registered manager had however not been working in the home. The provider had been overseeing the management of the home during this time and a new interim manager had recently been appointed.

The interim manager had a good knowledge of the home and was working in partnership with the provider to complete an action plan for improvement. Both the provider and the interim manager had been open about the shortfalls at Linwood and how these were being addressed. We identified that there was a gap between the leadership from the provider and the day to day monitoring of care practices. The action plan for the home had also highlighted this issue and the interim manager was clear about how this was being managed.

We found that there were some occasions when people had not received their medicines as indicated on their Medication Administration Record (MAR). In two cases this was because recent advice from the person’s doctor had not been reflected on the MAR. In other cases it was due to staff not correctly recording the medicines they had administered.

We found that a number of new staff had been recruited. In some cases however, the necessary information to show that appropriate checks of people’s employment history was not in place. We saw that a number of staff had been responsible for gathering recruitment information which meant that no one had assumed responsibility for ensuring the correct processes had been followed.

People told us that they were happy with the care they received and said that they felt well looked after. One person told us that they had noticed definite improvements since the last inspection, in particular that there were more staff around to support them. A relative also told us “There are more staff about.”

Staff told us that “Things are much better” and said that the interim manager provided very clear leadership and direction. Staff said that the new staffing structure enabled them to provide better care to people because they had more time to spend with them. We saw that staff were better engaged with people at this inspection and encouraging them to participate in activities that were meaningful to them.

We read that where risks had been identified in respect of people’s hydration, weight or skin integrity, appropriate monitoring systems had been put in place. For example one person was receiving end of life care and steps had been taken to ensure she remained as comfortable and pain free as possible.

People were protected from harm because staff had a clear understanding about their roles and responsibilities in relation to safeguarding. People told us that they felt “Safe” at Linwood. Staff were able to describe what they would do if they ever had any concerns about abuse.

We found a number of breaches 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 this report.

Linwood is a care home that provides personal care for up to 67 people. Some of the people at Linwood are living with dementia. The home is set across three floors and has a spacious back garden.

At the time of our inspection 58 people were living at Linwood. This inspection took place on 11 June 2015 and was unannounced.

The home is run by a registered manager, who was present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

There was an insufficient number of qualified staff deployed to meet the needs of all people who required care. Risk assessments were in place, however people were placed at risk of harm as appropriate guidance and best practice was not always followed.

Staff understood what to look for when they suspected abuse, they did not know how to report it outside of the company. We have made a recommendation about staff reporting concerns about abuse to the local authority.

Staff did not have a clear understanding of their responsibilities regarding the Mental Capacity Act or Deprivation of Liberty Safeguards. Where people lacked capacity they were not fully protected and best practices were not being followed in accordance with the Mental Capacity Act.

Where restrictions on people were in place to deprive them of their liberty, there was confusion as to the progress of each application, in line with the legal requirements to make sure this was done in the person’s best interest. The registered manager had submitted Deprivation of Liberty Safeguards (DoLS) applications to comply with their responsibilities. We have made a recommendation that arrangements and best practices are followed in accordance with current legislation.

The environment was not conducive for people living with dementia or sensory impairment, as the décor was of the same colour and no distinction between sections of the home, it was difficult to assist people’s orientation as they may find it difficult to find their way around without there being some adaptation to the environment. We have made a recommendation that the provider to make the environment used by people who live with dementia more ‘dementia friendly’.

We noted that there were inconsistencies in the care people received. We observed some incidences of improper care. There were also inconsistencies about how people were involved in making decisions about their cafe and treatment.

We observed good and poor examples of how staff knew and responded to people’s needs. Care was not always based on individual needs, care and treatment. People had access to activities, however there were mixed feelings about the activities provided. People were protected from social isolation through systems the service had in place. We found there was a range of activities available within the service and the local community, however not all of the activities were age appropriate or stimulated people. We have made a recommendation that the provider reviews activities in line with people’s interests and hobbies.

The management and leadership of the home were ineffective. We were concerned about the lack of understanding or knowledge of people living at the home by the management team. They were unable to accurately recall the number of people living in the home, for whom DoLS applications had been made or that a person was unwell.

There were quality assurance systems in place, to review and monitor the quality of service provided, however they were not robust or effective at identifying and correcting poor care or practices. This meant that whilst there were arrangements in place to manage standards, people were not fully protected against the risks as there was no systematic approach to managing them.

People told us that they felt safe at Linwood. People told us, “We are looked after very safely here.” Staff had a good understanding about the signs of abuse, however apart from reporting the incident to their manager; they did not know what to do. There were systems and processes in place to protect people from abuse.

Recruitment practices were safe and relevant checks had been completed before staff commenced work. Medicines were managed safely. Any changes to people’s medicines were prescribed by the person’s GP.

People’s preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people’s wishes. People’s relatives and friends were able to visit. Staff told us they always made sure they respected people’s privacy and dignity before personal care tasks were performed.

People had enough to eat and drink throughout the day and there were arrangements in place to identify and support people who were nutritionally at risk. People were supported to have access to healthcare services and healthcare professional were involved in the regular monitoring of people’s health. The service worked effectively with health care professionals and referred people for treatment when necessary.

People told us if they had any issues they would speak to the manager. People were encouraged to voice their concerns or complaints about the service and there were different ways for their voice to be heard.

We found a number of breaches 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 this report.

On this inspection we looked at whether improvements had been made in relation to respect and involvement and care and welfare. We looked at whether staff had received safeguarding training and that there were sufficient numbers of staff for people’s needs. We looked at whether had received appropriate training for their role, that the home assessed and monitored the quality of the service. We took with us a specialist in dementia to look at whether the service provided the appropriate care for people.

We found that people received the meals that they had chosen. We saw that regular residents meetings were held. However not all of the people’s clothes were ironed. We could still smell smoke in one corridor where one person smoked in their room.

We saw that staff were kind and caring towards people. Staff gave an understanding of people’s needs and we saw that people responded positively to staff. One person told us “The staff are very good – if you ask them they try and help you.”

We found that on most days there were sufficient numbers of staff for people’s needs.

We looked to see that staff had received all of the training appropriate to their roles and confirmed that they had.

There were some systems in place that assessed and monitored the quality of the service. We were shown evidence of some annual audits and actions plans that addressed any issues raised. However we found that these were not always followed up.

We inspected this service on the 29 & 30 March 2013 and found that the provider had failed to comply with the essential standard of quality and safety for the following outcomes: involvement and respect, care and welfare, safeguarding, staffing, supporting workers, assessing and monitoring the quality and safety of the service and records.

We took enforcement action that ensured the provider protected people’s safety and welfare in relation to the following outcomes: staffing and supporting workers.

This inspection on the 04 June 2013 was carried out to check whether the provider had taken action to protect people’s safety and welfare and to achieve compliance.

During this inspection we spoke to 4 relatives and 2 people who used the service. We also observed care being given. Comments from people and relatives included “I’m not totally displeased with the service”, “Things are definitely better”, “The (staff) improvements are not consistent.”

We found that the provider had taken action to improve the levels of staff to meet people’s needs, However we found that people still remained at risk as the service did not always have the minimum amounts of staff required on duty.

We found on this inspection that whilst we saw that some staff had undergone some mandatory training and 1-1 supervisions with their manager since the last inspection this was not consistent. We found that meetings had increased for staff and that these provided regular support.

Due to the needs of the people who use the service it was difficult to seek the views of many people. Some people told us that staff were kind and they could ask them anything. A relative told us that nothing was too much trouble for the staff and that they had lots of patience. People confirmed that they thought they had care plans but they could not recall signing them. We spoke to relatives during our visit who did recall seeing care plans and signing and agreeing them following consultation.

We were told that people using the service enjoyed the food and that there was always plenty to eat. Some people also stated their room was cleaned regularly and they thought the standard of cleanliness was acceptable and they liked their bedrooms and communal areas.

People who use the service that were able to talk with us told us the staff were kind to them and helped them when they needed assistance.

We visited Linwood to look at the care and welfare of people who used the service.

Our inspection team was made up of two inspectors. We asked our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We saw that people were treated with respect and in a dignified way by the staff.

People and their relatives told us they felt safe.

There were systems in place to record accidents and incidents, complaints, concerns, whistleblowing and investigations.

We saw the service was safe, clean and hygienic.

Recruitment practices were safe.

Is the service effective?

People's health and care needs were assessed with them.

Specialist dietary, mobility and equipment needs had been identified and implemented in care plans where required.

People's needs were taken into account with the layout of the service enabling people to move around freely and safely. The premises had been sensitively adapted to meet the needs of people with physical impairments.

Is the service caring?

People were supported by kind and attentive staff. We saw staff gave encouragement when supporting people. People commented, "This is a good home with kind staff.” A relative said, “I am happy with the care and support that is given to my family member.”

A sample of people who used the service and their relatives, involved with the service completed monthly satisfaction surveys. This was because the manager was new to the home and wanted to monitor progress. Where shortfalls or concerns were raised these were addressed.

Feedback and comment forms were available in reception. We saw a selection of comments made for March, April and May this year. These comments included “Staff friendly and welcoming” and “Linwood is a very professional place.”

Staff were able to tell us about the people they supported. They knew people’s individual support needs without having to refer to the care records. Staff were seen to take time to talk and listen to what people said.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

We saw that people completed a range of activities.

People were able to keep in contact with friends and relatives.

People knew how to make a complaint if they were unhappy. Information about how to do this was displayed in the reception area. The people we spoke with told us they had never felt the need to complain.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service has a quality assurance system that checked a number of aspects of the service. We saw that where a need for improvement had been identified these were corrected quickly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the values of the home and the organisation they worked for.

Quality assurance processes were in place. The manager regularly checked on how the service was performing. This helped to ensure that people received a good quality service at all times.

Senior managers regularly visited the home to make sure that people and staff were happy.

You can see our judgements on the front page of this report.