About the service: Lindisfarne Crawcrook provides accommodation with personal and nursing care for up to 60 older people and people living with dementia. At the time of this inspection 57 people were living at the service.

People’s experience of using this service: Staff were making a difference to people’s wellbeing by working well as a team, in harmony with one another and by sharing the same values and principles.

We found that staff were totally committed to delivering a service which improved people’s lives in fulfilling and creative ways. Their drive and passion had created a dynamic and vibrant service.

Staff focused fully on the goals and aspirations of the people who used the service. People on the downstairs unit told us that the staff had enabled them to rebuild their relationships with family members and this meant a great deal to them.

Staff took steps to safeguard vulnerable adults and promoted their human rights. Incidents were dealt with appropriately, which helped to keep people safe. People’s health needs were identified and external professionals involved if necessary.

People participated in a range of activities that met their individual choices and preferences. Staff understood the importance of this and provided the structured support people required. This enabled people to achieve positive outcomes and promoted a good quality of life.

Staffing levels met people’s needs. Staff had received a wide range of training including around working with people who may display behaviours that challenge. Checks were made on the ongoing competency of staff.

The cook and staff had received ‘focus on under-nutrition’ training. Staff were encouraging people who were under-weight to eat fortified foods. A range of menu choices were available.

People participated in a range of activities that met their individual choices and preferences. Staff provided the structured support people required.

The registered manager had acted on concerns and complaints and had taken steps to resolve these matters. All incidents were analysed and lessons were learnt and embedded into practice.

The service was well run. The senior managers and registered manager carried out lots of checks to make sure that the service was effective. The registered manager continually researched information about best practice and ensured staff practice remained at the forefront in introducing new guidance.

For more details, please see the full report which is on CQC website at www.cqc.org.uk

Rating at last inspection: Good (report published 20 September 2016).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

This was an unannounced inspection which we carried out on 28 July 2016. We inspected the service to follow up on the breaches and to carry out a comprehensive inspection.

Lindisfarne Crawcrook provides personal and nursing care to a maximum of 60 older people, including people who live with dementia or dementia related conditions.

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.

We last inspected Lindisfarne Crawcrook in August 2015. At that inspection we found the service was in breach of its legal requirements with regard to person centred care, premises and equipment, good governance and staffing. This was because records did not contain all the information needed to ensure people received appropriate care that met their needs. The auditing arrangements were not effective to ensure people received appropriate care. Arrangements were not in place to ensure people enjoyed a pleasant dining experience to support their nutrition and hydration. Standards of hygiene were not always satisfactory and the home was not well maintained and designed for the needs of people who lived there.

Due to their health conditions and complex needs not all people were able to share their views about the service they received. Those that could speak with us told us that care was provided with kindness and we observed that people’s privacy and dignity were respected. Staff knew the people they were supporting well.

We found improvements had been made to ensure the safe care and treatment of people. People told us they felt safe and there were enough staff on duty. Staffing had been reviewed and increased so staff now had more time to interact and spend time with people and not just when they carried out tasks.

Risk assessments were in place and they accurately identified current risks to the person as well as ways for staff to minimise or appropriately manage those risks. People were protected as staff had received training about safeguarding and knew how to respond to any allegation of abuse. Staff received opportunities for training to meet peoples’ care needs and in a safe way. A system was in place for staff to receive supervision and appraisal and there were robust recruitment processes being used when staff were employed.

Staff had received training and had a good understanding of the Mental Capacity Act 2005 and best interest decision making, when people were unable to make decisions themselves. People were able to make choices where they were able about aspects of their daily lives. People had access to health care professionals to make sure they received appropriate care and treatment. Staff followed advice given by professionals to make sure people received the care they needed. People received their medicines in a safe and timely way.

A complaints procedure was available. People told us they felt confident to speak to staff about any concerns if they needed to. Staff and people who used the service said the registered manager was supportive and approachable. People had the opportunity to give their views about the service. Feedback was acted upon in order to ensure improvements were made to the service when required. The provider undertook a range of audits to check on the quality of care provided. Records had been updated and they were regularly reviewed to reflect peoples’ care and support requirements.

Changes had been made to the environment. It was cleaner and brighter and areas had been refurbished. Menus were varied and a choice was offered at each mealtime. Staff supported people who required help to eat and drink and special diets were catered for. Some activities and entertainment were available for

This was an unannounced inspection carried out on 5 August 2015.

We last inspected Lindisfarne Crawcrook in April 2014. At that inspection we found the service was meeting all legal requirements.

Lindisfarne Crawcrook is a 60 bed care home that provides personal and nursing care to older people, including people who live with dementia or a dementia related condition.

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.

People said they felt safe and they could speak to staff as they were approachable. We had concerns however that there were not enough staff on duty to provide safe and individual care to people.

People were protected as staff had received training about safeguarding and knew how to respond to any allegation of abuse. When new staff were appointed, thorough vetting checks were carried out to make sure they were suitable to work with people who needed care and support.

People received their medicines in a safe way. However we have made a recommendation about some aspects of medicines management.

Not all areas of the home were clean and well maintained for the comfort of people who used the service.

Staff undertook risk assessments where required and people were routinely assessed against a range of potential risks, such as falls, mobility, skin damage and nutrition.

People had access to health care professionals to make sure they received appropriate care and treatment.

Lindisfarne Crawcrook was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Best interest decisions were made appropriately on behalf of people, when they were unable to give consent to their care and treatment.

People did not all receive a varied and balanced diet to meet their nutritional needs.

People said staff were kind and caring. However we saw staff did not always interact and talk with people when they had the opportunity. There was an emphasis from staff on supervision and task centred care.

There were limited activities and entertainment provided by the activities person. When they were not available, other staff did not provide activities for people to remain stimulated. Relatives we spoke with said more activities and stimulation needed to be provided for people.

A complaints procedure was available. People told us they would feel confident to speak to staff about any concerns if they needed to.

People said the manager was supportive and approachable.

The home had a quality assurance programme to check the quality of care provided. However the systems used to assess the quality of the service had not identified the issues that we found during the inspection to ensure people received individual care that met their needs.

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

We considered our inspection findings to answer questions we always ask:

. Is the service safe?

. Is the service effective?

. Is the service caring?

. Is the service responsive?

. Is the service well-led?

This is the summary of what we found.

Is the service safe?

An assessment of people's care and support needs was carried out before people started to use the service. This was to ensure staff had the skills and had received the training in order to meet the person's support requirements.

Risk assessments were in place. People were supported and encouraged to maintain their independence and this was balanced with the risk to the person. Audits were carried out to look at accidents and incidents and the necessary action was taken to keep people safe.

Information was available to show that the service worked with other agencies to try to prevent admissions to hospital wherever possible.

Regular checks of fire equipment and fire drills were carried out to ensure the safety of people who used the service and staff. There were currently enough staff on duty to meet the needs of the people who used the service. The number of domestic staff needs to be kept under review as occupancy levels increase to ensure a clean and hygienic environment at all times.

Is the service effective?

People we spoke with were positive about the service provided. People commented how helpful and friendly the workers were. Relatives told us the service kept them up to date with what was happening with their relative's care and they felt able to ask any questions.

Staff we spoke with were knowledgeable about people's care needs. They had received training to help them understand the different care and support needs of people they worked with. Staff who worked with people who lived with dementia were observed to be patient and supportive as they worked with people. This was particularly noticeable in the top floor lounges where there was an excellent camaraderie and staff were enthusiastic and interacted with people at all times. This was not evident in the main downstairs lounge where people sat without any interaction, when the activities organiser was not present, and the member of staff sat reading a magazine.

Is the service caring?

People and relatives spoken with talked well of the level of care provided by staff. Comments included; "My wife has settled well here, much more than the last place she was." We found people were encouraged to be involved in daily decision making. Staff were helpful and offered people information and support about their care. People said they could ask questions if they were not sure what was happening to them or raise any concerns with staff who were all very approachable.

People who used the service were always accompanied by a person to hospital, if a visit was necessary, and the worker stayed with them until a family member arrived or they were admitted to a ward. This was to ensure that hospital staff could be given all the appropriate information and to support the person during their hospital appointment or admission.

Is the service responsive?

Information was collected by the service with regard to the person's ability and level of independence before they moved into the service. Various assessments were completed by the manager of the service with the person and/or their family to help make sure staff could meet their needs. Regular reviews were carried out with the person who used the service and their representative to make sure the person's care and support needs had not changed. This helped ensure staff supplied the correct amount of care and support.

Referrals for specialist advice where made when staff needed guidance to ensure the health needs of people were met.

People's individual needs were taken into account and they, or their representative if they were not able, were involved in all decision making with regard to their care. They were kept informed and given information to help them understand the care and choices available to them.

Information collected by the service gave staff some insight into the interests and areas of importance to the person. It helped with the provision of social activities people may wish to be involved with.

Regular meetings took place with staff to discuss the running of the service and to ensure the service was responsive in meeting the changing needs of people.

Is the service well-led?

There was a focus from management on the provision of individual care and support to people who use the service. Staff were knowledgeable about the support needs of people.

Staff received regular supervision and commented they felt supported by the management team and advice and support was available from the management team.

We saw people had the opportunity to comment on the quality of the service and that they felt able to speak to the manager and staff about any issues. Survey comments included; " The home is well managed." Two people commented however they did not feel confident any action would be taken; "Approachable but little seems to get done." And; "Listen then nothing done." This was also apparent at the time of inspection as safety gates against some people's doors were still in use despite previous inspections highlighting it was not good practice to use them.

The reason for this visit was to check if improvements had been made in areas of care and welfare, the premises, staffing and quality assurance following a previous inspection. We spoke with some people who received care but, due to their needs, some were unable to communicate with us. One person said; “I like the new curtains." Other positive comments were made about changes to the decor.

Some relatives we spoke with were appreciative of the care provided by the home. One person said;" My mother has always been happy at the home thanks to the constant kindness and care of the staff." Another person said; "My father has settled very well here thanks to the staff, they are excellent."

Records showed care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

We found staffing levels had increased at night which ensured there were enough qualified, skilled and experienced staff to meet people's needs.

The premises were better maintained so people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We saw the provider had an effective system to regularly assess and monitor the quality of service that people received.

We used a number of different methods to help us understand the experiences of people using the service, because most of the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke to the relatives of two people who told us:

"People are well looked after."

"The care is excellent."

"We're informed of any changes in our relative's condition."

"We attend meetings every three months."

"The staff are very helpful."

"The manager is approachable."

" I know who to speak to if I had a concern."

"The food is good."

We decided to visit the home at 6:00am to gain a wider view of the service provided. This was part of an out of normal hours pilot project being undertaken in the North East region.

We used a number of different methods which included observation to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences.

We saw staff were very busy as they provided care and support to people who used the service. We spoke to three people who lived at the home and one relative who told us staff were kind and helpful but they were kept very busy.

We observed staff were rushed as they tried to provide individual care to each person. Due to the low staff numbers on duty and the high dependency of many people care and support was not provided in a timely way as people had to wait for staff support. At times they were at risk due to inadequate observation. We also saw some people were not able to have choice when to get up in the morning.

We found the building was not well maintained or suitably designed for the needs of people with dementia.

We saw the provider had some systems in place to gather feedback from people, who used the service, and to regularly assess and monitor the quality of service people received.