This inspection took place on 15 June 2017 and it was unannounced. Linden Manor provides a service for up to 28 people who have a range of care needs including dementia, sensory impairment and physical disabilities. There were eight people living in the service at the time of the inspection.

At our last inspection on 8 June 2016, while improvements had been made, we did not revise the ratings for the key questions; safe, effective, responsive and well-led. As to improve the ratings to 'Good' required a longer term track record of consistent good practice. At this inspection we found the provider had consistently maintained good practice.

Since the last inspection there had been a change of management, a new manager had been appointed and they were going through the process to register with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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.

Improvements had been made to ensure individual risks were managed in a safe way. People's risk assessments reflected their current needs.

Improvements had been made to ensure robust recruitment checks were carried out and the staffing numbers were sufficient to meet the needs of people currently using the service.

Improvements had been made to ensure people were protected by the prevention and control of infection.

The service worked to the Mental Capacity Act 2005 key principles. People's consent was sought in line with legislation and guidance. Improvements had been made to ensure assessments of capacity were carried out where needed.

People were supported to receive sufficient nutrition and hydration and maintain good health. Systems were in place to ensure that health conditions were consistently monitored and people had access to the support of healthcare professionals in a timely manner.

People received personalised care that was responsive to their needs. Improvements had been made regarding internal quality monitoring systems, to support the service to deliver good quality care.

People felt safe living at the service. Staff had been trained to recognise signs of potential abuse and keep people safe.

Systems were in place to ensure people's daily medicines were managed in a safe way and that they got their medication when they needed it.

Staff had the right skills and training to meet people's needs, they were motivated to provide care and support in a caring and compassionate way. People's privacy and dignity was respected and promoted.

Systems were in place to enable people to raise concerns or make a complaint. The quality monitoring systems had been strengthened to ensure that routine management checks were carried out to cover all aspects of the service delivery.

This inspection took place on 8 June 2016. It was unannounced.

Linden Manor provides a service for up to 28 people who have a range of care needs including dementia, sensory impairment and physical disabilities. There were 11 people living in the home on the day of this inspection, although one person was in hospital.

At our last comprehensive inspection on 7 October 2015, we found that the service was in breach of legal requirements in a number of areas. The overall rating for the service at that time was ‘Inadequate’ and the service was put in ‘Special measures’. Services in special measures are kept under close review. We also imposed a condition of registration to suspend new admissions to the service until improvements had been made and the service was no longer in breach of legal requirements.

After the inspection we had a meeting with the provider to discuss our concerns, and they sent us regular updates outlining the actions they were taking to improve the service. This inspection was carried out to check the provider had made the required improvements. We found that they had done so.

A registered manager was not 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. However, a new manager had been appointed who confirmed she had begun the process to register with CQC.

Improvements had been made to ensure individual risks were managed in a safe way. However, further work was required to ensure people’s risk assessments reflect their current needs, and ensure staff have adequate guidance in terms of the control measures to follow where risks are identified.

There were sufficient numbers of suitable staff. Improvements had been made to ensure robust checks were being carried out for all staff, to make sure they were suitable to work at the service.

Improvements had been made to ensure people were protected by the prevention and control of infection.

Improvements had been made in terms of the leadership and management of the home. A new manager and area manager had been appointed, who were providing effective leadership at the service.

We found that the service worked to the Mental Capacity Act 2005 key principles, which meant that people’s consent was sought in line with legislation and guidance. However, improvements were required to ensure assessments of capacity were available and clear.

People were supported to have sufficient to eat and drink. However, some people required different eating aids, to enhance their independence and overall meal time experience.

People were supported to maintain good health and have access to relevant healthcare services. Some improvements were required however, to ensure people’s health conditions were consistently monitored and appropriate action taken in a timely manner.

People received personalised care that was responsive to their needs. Although, some care records needed reviewing; to ensure the care recorded met each person’s current needs and also reflected their involvement.

Improvements had also been made regarding internal quality monitoring systems, to support the service to deliver good quality care. However, there was still room to improve these further, particularly in terms of auditing people's care records.

People felt safe living at the service. Staff had been trained to recognise signs of potential abuse and keep people safe.

Systems were in place to ensure people’s daily medicines were managed in a safe way and that they got their medication when they needed it.

Staff had the right skills and training to meet people’s needs.

Staff were motivated and provided care and support in a caring and meaningful way.

Staff listened to people and supported them to make their own decisions as fa

Linden Manor provides a service for up to 28 older people, who may have a range of care needs including dementia, sensory impairments and physical disabilities. There were 19 people living in the home on the day of this inspection.

We carried out an unannounced comprehensive inspection of this service on 5 March 2015 and found legal requirements had been breached.

We also reported that the home had been operating under an administration company since May 2012, along with 16 other services, due to the financial difficulties of the previous provider. In April 2015, we were informed that a new owner had acquired the home, but had kept the same provider name (legal entity). A representative for the new owner wrote to us to say what they would do to meet legal requirements; to ensure people using the service were protected against the risks associated with unsafe or unsuitable premises, because of the design and layout.

We undertook this inspection to check that they had followed their plan and to confirm they now met legal requirements.

Since the last inspection in March, the Care Quality Commission (CQC) has received information about a number of concerns relating to the service. These included concerns about staffing levels and dementia care provision. We looked at these concerns during this inspection too.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection took place on 7 October 2015 and was unannounced. We found a number of concerns and areas where improvements were required:

Processes in place to manage identifiable risks within the service were not sufficiently robust.

There were insufficient numbers of staff to keep people safe and meet their needs.

The provider carried out recruitment checks on new staff to make sure they were suitable to work at the service, but these did not fully meet legal requirements.

Parts of the premises and equipment used by people living in the home were not adequately clean or used properly.

There were inconsistencies in the way the service worked to the Mental Capacity Act 2005 key principles, which meant that people’s consent was not always sought in line with legislation and guidance.

People had enough to eat and drink, but assistance to eat was not provided adequately where this was required.

The staff were kind and caring, but there were missed opportunities for meaningful engagement with people.

People were not fully involved in making and planning their own care.

People’s dignity was not consistently upheld.

People did not receive personalised care that was responsive to their needs.

People’s social needs were not provided for and they did not have adequate opportunities to participate in meaningful activities.

People were given opportunities to express their views on the service and raise concerns, but this feedback was not always acted on.

There were ineffective management and leadership arrangements in place.

The systems in place to monitor the quality of the service provided and drive continuous improvement, were also inadequate.

Staff had been trained to recognise signs of potential abuse and keep people safe.

Systems were in place to ensure people’s daily medicines were managed in a safe way, and that they got their medication when they needed it.

Staff had received training to carry out their roles and meet people’s assessed needs.

People’s healthcare needs were met. The service had developed positive working relationships with external healthcare professionals; to ensure effective arrangements were in place to meet people’s healthcare needs.

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 registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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

This inspection took place on 05 March 2015 and was unannounced.

Linden Manor is registered to provide accommodation for persons who require nursing or personal care. The service is registered to provide care for up to 28 older people with conditions such as dementia, sensory impairments and physical disabilities who do not require nursing. At the time of our inspection there were 22 people using the service.

At our previous inspection on 19 August 2014 we found that some specific information was missing from care plans which meant people were at risk if they were cared for by staff that were not familiar with them. We also found that there were areas of the home that were not clean and exposed people to the risk of infection and there were insufficient staff on duty to meet the needs of the people using the service. We asked the provider to provide us with an action plan to address this and to inform us when this was complete. During this inspection we looked at these areas to see whether or not improvements had been made. We found that the provider was now meeting these regulations.

The service 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.

People were not protected against the risks associated with unsafe or unsuitable premises by means of suitable design and layout.

We found that people were protected from abuse and felt safe.

Staff were knowledgeable about risks of abuse and there were suitable systems in place for recording, reporting and investigating incidents.

Staffing levels were sufficient to meet people’s needs.

Staff had been recruited using effective recruitment processes so that people were kept safe and free from harm.

Where needed, people’s medications were managed so that they received them safely.

Staff were well trained and had good understanding of their role and key legislation. Staff were regularly supervised by senior staff and management.

Staff had received training in the Mental Capacity Act (MCA) and policies for the MCA and Deprivation of Liberty Safeguards (DoLS) were in place. The provider had not applied to the local authority to deprive people of their liberty at the time of our visit, but had completed applications where necessary shortly after.

Care was delivered in a person-centred way which promoted people’s independence, privacy and dignity.

People could make choices about their food and drink and were provided with support when required to prepare meals.

People were supported to make and attend health appointments when required.

Staff were caring and ensured that people’s privacy and dignity was respected at all times.

People and their visitors were involved in making decisions and planning their care, and their views were listened to and acted upon.

Staff were knowledgeable about the needs of individual people they supported. People were supported to make choices around their care and daily lives.

We found that the service listened to what people said about the care they received and took active steps to encourage feedback from each person and their families.

Management systems were in place to maintain quality and address issues in a timely manner.

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

We considered all the evidence we had gathered under the outcomes we inspected during our inspection at Linden Manor Care Home. 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 to people’s needs?

• Is the service well led?

This is a summary of what we found:

Is the service safe?

We found that the home did not have robust arrangements in place to ensure that people who used the service were safe and that their health and welfare needs were met. This was because there were not enough skilled and experienced staff to meet their needs at all times. We asked the provider to tell us what they were going to do in relation to ensuring there were sufficient staff on duty to meet people's assessed needs.

Some areas of the home had been redecorated, however we noted that some areas were not appropriately cleaned and a frayed carpet at a threshold was a potential hazard to the people using the service. We asked the provider to tell us what they were going to do in relation to ensuring people lived in a safe clean environment.

Is the service effective?

Staff we spoke with had a good understanding of people’s needs and knew how they preferred to be supported. However staffing shortages meant that care could not always be provided in a way that supported these preferences and people's interests.

People told us they liked the food. One person said, “The food is always good.” We saw that people’s nutritional needs were met and the staff knew how to seek advice and support if necessary.

Is the service caring?

During our visit we observed positive interactions between the staff and the people who used the service. People were supported and spoken to in a kindly manner by all of the staff. One person said, “Everyone is nice, they look after us.” A visitor told us that they felt welcome in the home at any time and the staff kept them informed of any changes in their loved ones condition.

The staff we spoke with had good knowledge about people’s medical conditions and needs. However the documentation was not written with specific instructions to ensure all staff would be able to provide the required level of care.

Is the service well led?

The registered manager was on leave during our inspection. Staff told us the manager was approachable and supportive and had made a number of positive changes to the environment in the time they had been managing the service. However the ratio of staff on duty to the number of people using the service meant some areas of people's care, particularly activities, were not being met. We also noted that areas of the home, particularly toilets were not as clean as they should be.

We considered all the evidence we had gathered under the outcomes we had inspected to answer questions we always ask; is the service caring? is the service responsive? is the service safe? is the service effective? is the service well lead?

This is a summary of what we found-

Is the service safe?

One person was able to tell us they felt safe living at Linden Manor. Individual plans of care contained risk assessments to promote people’s safety such as risk assessments for malnutrition, the risk of falls, the effects of pressure on the body and movement and handling.

We saw bedrooms were fitted with appropriate safety equipment such as window restrictors, radiator guards, call bells and fire doors were fitted with automatic closure devices. We found both the bedrooms and the communal living areas were either fitted with non-slip flooring or carpets. No slip or trip hazards were identified. We looked at the accident records and found that there had been no accidents where the cause had been attributed to the safety of the environment. We saw when accidents had occurred they had been followed up to ensure that people had not sustained an injury. Where people had sustained injury appropriate medical advice had been sought.

We found that staffing levels were regularly reviewed to ensure that people’s individual and collective needs could be met and that a training plan was in place to ensure staff had the right skills to care for people safely.

Is the service effective?

All of the people living at Linden Manor had an individual plan of care; these had been regularly reviewed to ensure that they contained appropriate information.

We saw people were comfortable and relaxed within their environment, people looked well cared for and they were dressed according to their age, gender, culture and the weather conditions. We saw that people had access to a range of aids and adaptations to support their independence and mobility.

However the provider may wish to note that during the morning the radio in the conservatory was set to play 1980’s pop music which may not have engaged people with dementia and who were in their 80’s.

Is the service caring?

One person was able to tell us that the staff were nice to them. We saw that staff treated people with respect and consideration and they were also mindful of people’s privacy.

We also observed that staff supported people to eat their meals with patience and consideration. We also observed that people who used the service were referred by their preferred name.

People looked well cared for and they were dressed according to their age, gender and the weather conditions. We saw that people had access to a range of aids and adaptations to support their mobility and independence.

Is the service responsive to people’s needs?

Staffing levels had been maintained at an appropriate level in relation to the assessed individual and collective needs of the people who used the service; this meant that the quality of care and support that staff were able to provide was maintained.

There were regular and varied activities that people could engage in if they chose to do so.

Records showed that people had access to appropriate care, including access to pressure relieving equipment. Records also showed that people had access to health professionals and NHS services.

Is the service well lead?

The registered manager and the provider had had conducted the appropriate checks to ensure that people who used the service were safe. Systems were in pace to ensure that staff had the right skills to care for people safely. Individual plans of care reflected people’s health care needs and personal preferences and these were regularly reviewed. Risk assessments were in place to reduce and manage the impact of identified risk factors. Identified risks were followed up with appropriate specialist such as the falls prevention service.

A range of audits were conducted on a regular basis to assure the quality the service provided. These included audits of the fire safety systems, hot water temperature safety checks, medication systems, infection control systems, health and safety systems and the safety of environment. Individual plans of care and risk assessments were also reviewed on a regular basis.

However the provider may wish to note that although people at risk of dehydration had fluid charts in place they were not always accurately completed; nor was their 24 hour intake calculated. Without this being done and reviewed on a daily basis the management could not be assured that people were in receipt of an adequate amount of fluids.

We spoke with four people living in the home who all spoke highly of the care they received. One person told us, “I couldn’t be happier. I have nothing to complain about, staff are excellent”. We also spoke with the relative of someone living in the home who told us that they were happy with the service their family member received. People told us that they enjoyed the food served in the home and that portion sizes were good.

We spoke with three members of staff who had a good knowledge of people’s care needs.

We observed staff responding to one person who repeatedly voiced dissatisfaction. We saw that some staff did not offer the person explanations or engage with the person in a respectful or appropriate manner. We observed staff responding to other people living in the home and saw that they were respectful and did offer explanations and reassurance where needed.

We saw that people using the service and their relatives had been able to give feedback about the service through quarterly satisfaction surveys. We looked at a selection of these and saw the feedback from people using the service and their relatives was positive.