This comprehensive inspection took place on 31 January and 1 February 2017 and was unannounced on the first day. We last inspected the home on 31 July and 1 August 2015. At that inspection we found that considerable improvements had been made following the previous inspection in January 2015. However during the inspection in July and August 2015 we found three breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following that inspection the provider wrote to us to tell us what actions they would take in order to comply with those regulations and when.

During this inspection we checked if those actions had been completed and we found the service to be compliant with all of the fundamental standards.

Wyndham Manor is a purpose built residential care home situated in a residential area of Cleator Moor and is within walking distance of the local amenities. The home is on three floors and all rooms are single occupancy with ensuite facilities. There are a number of suitable shared communal areas and a secure garden. The home can take up to 68 people, some of whom may be living dementia. At the time of this inspection there were 61 people living at Wyndham Manor Care Home.

There was a registered manager in post. 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 about how the service is run.

Medicines were being administered and recorded appropriately and were being kept safely.

During the inspection there were sufficient numbers of suitable staff to meet people’s needs and the provider was in the process of recruiting more staff. Staff had completed a variety of training that enabled them to improve their knowledge in order to deliver care and treatment safely.

Where safeguarding concerns or incidents had occurred these had been reported by the registered manager to the appropriate authorities and we could see records of the actions that had been taken by the home to protect people.

People’s rights were protected. The registered manager was knowledgeable about their responsibilities under the Mental Capacity Act 2005. People were only deprived of their liberty if this had been authorised by the appropriate body or where applications had been made to do so.

People were supported to maintain good health and appropriate referrals to other healthcare professionals had been made.

There was a clear management structure in place and staff were happy with the level of support they received.

People living in the home were supported to access activities that were made available to them and pastimes of their choice.

Auditing and quality monitoring systems were in place that allowed the service to demonstrate effectively the safety and quality of the home.

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?

Our inspection took place on the Dent unit of Wyndham Manor Care Home. This report relates to our findings on that unit. This is a summary of what we found.

Is the service safe?

Safeguarding procedures were not robust. Less than half of the staff team had received safeguarding and adult protection training and no one had received training with regards to the Mental Capacity Act 2005.

We looked at a sample of four people’s care plans in detail. We did not see any evidence of mental capacity assessments or best interest statements in any of the records we looked at. Care plans contained very little detail regarding the mental health needs, psychological and emotional needs of the people who used this service. The lack of detail with regard to this type of information was concerning, particularly as this was the dementia unit at the home.

There were no systems in place to make sure that the manager and staff learned from events such as accidents, incidents, complaints or concerns. This raised the risk of harm to people and failed to ensure lessons were learned from mistakes.

We found some shortfalls in the way infection control and prevention was managed at the home. Communal bathrooms, shower rooms and toilets were not equipped with hand washing facilities. There were no soap dispensers or paper towels available in these areas. No one was able to wash their hands immediately following the use of these facilities. This raised the risk of cross contamination and poor infection control.

We identified some concerns in the way people had been supported with their medicines. For example some medicines were being “crushed” or added to food products during administration. There was no evidence of capacity assessment, GP or pharmacy involvement to show that this was safe and appropriate or that medicines were not being administered covertly.

Is the service effective?

We found that people had received assessments of their care and support needs. Information had been transferred into care plans but these did not contain sufficient information, particularly where people needed help with specialist medical conditions, behaviours or nutrition. Care plans were therefore not able to support staff consistently to meet people’s needs.

We looked at the staff training matrix and spoke to the managers about the staff training programme. We found that staff had not been provided with sufficient training to enable them to meet people’s needs in a safe and consistent manner.

We spoke to a speech and language therapist who told us they had worked with the manager and the staff and provided some training. They said, “Staff follow instructions and advice and there is good detail in care plans.”

A visitor to the home said, “The personal care provided to my relative is good, I am happy with that. My relative has a choice of what to do during the day.”

We spoke to a person who lived at Wyndham Manor. They told us that they were “happy” at the home. This person appeared well presented and well cared for.

Is the service caring?

During our time spent in the home we saw that staff were constantly busy supporting people with their daily needs. We observed some caring support and interactions between staff and people who used the service. However, we did see some negative staff practices, which could have been due to lack of knowledge, time or a combination of both.

More than half of the people that lived on Dent unit needed support from one or more care staff in order to meet their daily needs.

The staff we spoke to told us that, “an extra member of staff would be helpful as there are many people who need two staff to help them.”

Staff told us that people who used the service sometimes had to wait for assistance. One member of staff said, “We prioritise people when getting them up in the morning. For example people who are awake or shouting out.” Another member of staff told us “I know the people I can leave (in bed) until later. We observed that staff were still helping people to get up at 11:30am.

One of the visitors to the home told us, “There are not always enough staff, they are pushed due to the type of people they look after. Staff are all busy so sometimes we cannot find anyone to speak to.”

The sample of care plans we looked at did not contain accurate and up to date information about people’s care and support needs. We saw that there were life story books and facilities to record people’s personal histories. Some contained very good, detailed information about the person but others contained very little information. This meant that care and support could not always be provided in accordance with people’s wishes.

Is the service responsive?

People’s needs had been assessed prior to them moving into the home. However, we found that care needs were not routinely reviewed and care plans were not updated to reflect any changes.

For example, one person’s record showed that they had no problems with swallowing or chewing. More recent records (their daily notes) recorded that they had a poor oral intake and that they had not been “swallowing well.” Their nutritional care plan had not been not reviewed or updated to reflect these changes.

Prior to our visit we had been told of an incident where a chair had collapsed underneath a person who used this service.

We asked the manager about this incident. She confirmed the event had occurred. We asked what measures had been put in place to ensure the furniture used by service users had been checked to ensure it was safe. The manager told us that she had not put anything in place and no audits of the furniture had been carried out.

Is the service well-led?

The sample of four people's care records we looked at showed a significant number of altercations and assaults between people who used this service. We checked the information we held about Wyndham Manor Care Home and found that we had not been told of any of these incidents.

We checked the incidents with social workers. They were not aware of the numbers of incidents that had occurred at the home. The home manager had not reported the incidents and had not followed Cumbria County Council’s safeguarding procedures.

The provider did not have an effective system in place to identify, assess and manage risks relating to the health, welfare and safety of people who used this service.

The sample of care records we looked at recorded some element of risk assessment. We found that where risks to health, welfare and safety had been identified, they had not been reviewed and updated in order to reflect the current risks.

We spoke to the relatives of one of the people who used this service. They told us that if they had any complaints or concerns they could speak to staff or the manager. They told us that they had experienced “no problems” and that staff were “good at responding and listening.” However, another relative told us that they had not experienced such a good response from the manager when they had raised a complaint. They told us that the “manager didn’t want to know and didn’t listen to the concerns I raised.”

We spoke with people who used the service, they told us that Wyndham Manor was a nice place to live. One person said, "It's good so far." Another person told us, "Oh yes, the carers look after me." Another added, "It's the best thing I've ever done coming here!"

During a previous inspection we had found the home to be non-compliant in the way they provided people with nutritional support. We found that the home had made improvements and that people were now satisfied with the way their nutritional needs were being met. A relative we spoke with told us "They're encouraging my Mam to eat more." People who used the service told us that the quality of the food had improved, one said "The food's very nice!" Another added "If I'm hungry they always find me something nice."

We looked at the way people were cared for and found that care was being delivered professionally and to an appropriate standard. Staff were able to liaise with other healthcare professionals and organisations to ensure good outcomes for the people they looked after. Staff told us that they felt supported by the manager of the home and that they were well trained. People who used the service felt that the staff were warm and friendly and knew how to do their jobs correctly. The manager and the provider had systems in place to monitor the quality of care provided in the home.

We spoke to people in the home about the food choices and the standards of catering. We also spoke to some people who had poor appetites or difficulties with swallowing. Some people were quite positive about the food:

"It is fine...some things are better than others...I like the soup when it is home made and the baking is always nice..."

"I enjoy everything that is put down to me...no complaints really, plenty and there are choices."

"We get dinner at 5 o'clock and I like that...only want a sandwich or something during the day...quite satisfied really."

Others were not so enthusiastic about the meals:

"It is all right I suppose but not really what I am used to..."

"I don't have any appetite and I get special drinks but I don't like them either...I do find eating difficult..."

We noted that people did not get a lot of fresh fruit and that on some days there was a reliance on frozen foods. Some people did notice this and wanted more fresh foods.

We went into the kitchen and found it to be clean and organised. We did have some concerns about some of the food preparation arrangements and we asked Environmental Health to go in and give the manager some advice.

We then looked at the written plans of care and we saw that these did not give enough direction and guidance for staff when people had problems with eating a balanced diet. We also met some people who were not eating or drinking enough and they were not always getting the right levels of support.

People in the service were only given support after they consented to care and treatment.

"No one forces anything on me...I am asked nicely and I can say no !"

People in the home were given good levels of care and treatment but we asked the provider to give staff more support in writing plans for people who might have challenging behaviour.

Although the food provided was of a good standard we found that one or two people needed more help and support to get good levels of nutrition. One or two nutritional plans needed more information.

People were very positive about the way the service is developing:

"In the last few months things have been totally different...much improved".

"Staff are lovely, they all know residents' needs".

"New staff pick up things quickly - I know they're being supported and learning from the older staff".

"Things have got even better since the home has a second deputy".

"I am quite content...We all get on well...We are all friends here. There is plenty to do and my room is lovely".

"We have settled well and are happy with our own company".

"I have plenty of friends here... we are fine no need to worry about us...".

We met a number of people during our site visit and these are some of the comments that were made:

"I am quite happy with this place...the staff are Ok and we get along fine"

"As a family we were very impressed with the care given to my relative at the end of life. The night staff were very good...".

"We haven't been here long but so far so good...we were helped to settle in really well and the staff were helpful and caring."

"I like my room and have all my things around me...I can spend time on my own when I want."

"I feel safe here and I trust the staff and the manager...nothing wrong with this place...they are all very kind."

This was an unannounced inspection that took place on 31 July and 1 August 2015. We carried out this inspection to check that improvements had been made following our previous inspections of the 15 and 28 January 2015. The findings of these previous visits led us to rate the home as inadequate and serve warning notices and compliance actions as the provider failed to meet all the requirements of the regulations.

At the inspection in January 2015 we found the home was in breach of the following regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010:

Regulation: 9 Care and Welfare of people who use services

Regulation: 10 Assessing and monitoring the quality of service provided

Regulation: 11 Safeguarding people who use services from abuse

Regulation: 12 Cleanliness and infection control

Regulation: 13 Management of medicines

Regulation: 14 Meeting nutritional needs

Regulation: 16 Safety, Availability and suitability of equipment

Regulation: 18 Consent to care and treatment

Regulation: 20 Records

Regulation: 23 Supporting staff

Regulation: 21 Requirements relating to workers.

In addition the home was failing to notify us of events they are required to by law. Which was a breach of Regulation: 18 of the Care Quality Commission (Registration) Regulations 2009; Notification of other incidents.

The above regulations have now been replaced with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We had asked the provider to make improvements in meeting people’s health and welfare needs, infection control, records, nutrition needs, safeguarding, safety and suitability of equipment, assessing and monitoring the quality of service and completing statutory notifications appropriately. We received an action plan from the provider detailing how these improvements would be made.

At this inspection of 31 July and 1 August 2015 we looked at all the areas where the home had breached the regulations set out above, and other areas to ensure that we carried out a fully comprehensive inspection. We found that there had been improvements across all areas that we looked at.

We found that the home was no longer in breach of the above regulations with the exception of Regulation: 14 Meeting nutritional and hydration needs.

We also found two new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation: 18 (Staffing) and 10 (Dignity and respect).

We found that the provider had not taken appropriate steps to ensure that, at all times, there were sufficient numbers of suitably qualified, skilled and experienced staff to meet people’s needs . This was in breach of Regulation: 18(1) Staffing.

We found a breach of Regulation: 10 Dignity and respect. The provider had not actively worked with people to maintain their involvement in their local community and had not ensured that people were not unnecessarily isolated.

There was no registered manager in post at the time of our inspection. This is a breach of the provider's condition of registration and we are dealing with this matter outside of the inspection process.

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.

Wyndham Manor is a purpose built residential care home situated in a residential area of Cleator Moor, Cumbria and is within walking distance of the local amenities. Accommodation and communal space is over three floors and all rooms are for single occupancy and have en-suite facilities. There are suitable shared areas and a garden. The home provides accommodation for up to 60 older people some of whom may be living with dementia.

We found that people’s care needs were being better met. People looked well cared for with good attention to detail to ensure people were well dressed and to their own taste. Call buzzers were answered promptly, and everyone we spoke to said they were well cared for by staff that were kind and caring. The atmosphere in the home was calm and orderly.

We judged the home to be safer because the provider had ensured that all staff had been given training to identify and report any potential harm or abuse of vulnerable adults. We had evidence to show that senior staff understood how to report, and where appropriate, manage any issues related to possible abuse.

Risk assessments related to the environment and the delivery of care were up to date. Accidents and incidents were managed correctly and reported to the appropriate authorities, including ourselves, CQC.

The home had recently employed a number of new staff and a further 11 where due to start once all employment checks had been completed. The home’s manager had introduced the paperwork for a staffing dependency tool to work out the right levels of staff to meet people’s needs. However this had not yet been put into action and we found that the staffing levels on the middle floor of the home were not sufficient to meet people’s needs, with staff reporting being “over stretched” on this floor. On the other floors the care needs of these people were generally being met with the exception of enough staff to allow people to go out of the home and engage in the local community. People living in the home told us they didn’t get out enough. Care staff also held this view.

We saw that the way staff were being utilised and deployed in the home had improved, with the addition of a “breakfast person” on each floor to help at this busy time and with more activity co-ordinators hours. We saw that senior staff were giving more of a lead and direction to staff to ensure people’s needs were met in an orderly and timely manner.

New staff were recruited properly and disciplinary action had been taken when staff were not fulfilling their job role.

We found that the provider had significantly improved the way medicines were managed. People received their medicines at the times they needed them and in a safe way.

Infection control had improved. The staff team had been suitably trained and had access to personal protective equipment. The home was clean and orderly.

All of the staff had received induction training. This had been followed up by training in all the core subjects the provider felt the team needed. Some staff had received further specialist training.

We did however identify a need for senior staff, including the manager, to have more in-depth training in the care and support of people who were living with dementia. We recommended that this should include developing a full dementia care strategy for the home on best practice in promoting consistent personalised care for people living with dementia.

We checked on staff supervision and appraisal and we found that the manager was in the process of updating these records and making them more in-depth. We saw good practice at a recently introduced staff handover session that used newly developed paperwork to communicate people’s changing needs.

People continued to tell us about the lack of variety in the food and menus offered. We found that there was a lack of detail in the dietary requirements of those people prone to weight loss, malnutrition and with specialist dietary requirements.

We observed mealtimes being much more orderly and staff were spending time and giving appropriate support and care to those people who needed more help. However we found that there was no overall strategy to focus on the quality and types of food offered to people who were at risk of malnutrition due to old age and for those who were living with dementia.

We saw evidence to show that the staff team sought support and advice from local GPs, community nurses, dieticians and mental health workers to promote peoples health and well-being. Healthcare and social services professionals told us that they had seen a marked improvement in the appropriateness of the referrals the home was making as staff were gaining confidence in their own skills and judgments.

The home’s environment had improved with new furniture purchased and suitable redecoration and refurbishment being done.

We judged that the care staff approach was much more individualised. Staff had been trained in delivering person centred care and we saw a much more focussed approach on the needs and strengths of people in the home. People told us the staff team were caring, respectful and supported them to retain as much dignity and independence as possible.

Assessment and care planning had been developed in more depth. A new style care plan had been introduced that was much clearer and with more detailed assessments of people’s needs. These plans were more person centred and were being regularly reviewed. There was a good level of detail that gave clear instructions to care staff. Care staff were given time to read these and both staff and people in the home were more involved in the development of the care plans.

Risk assessments were better developed and tools were being used to assess risks to people’s health and wellbeing. We found that some care plans still required more detail, particularly when a person had a more complex healthcare needs. We saw that some staff required more training on how to use risk assessment tools associated with these more complex healthcare needs.

Care planning now identified in more detail the needs of those people whose behaviour may challenge the service. These now gave staff more detailed guidance on the most appropriate approach. These had been based on training and guidance given by social and healthcare professionals. Staff told us they were more confident in supporting people.

While we found people’s personal care needs were being better met we found that community involvement and socialising outside of the home was limited due to staffing levels.

Activities and entertainments within the home had improved significantly, with activity coordinators engaging people in activities they found interesting and stimulating. The arts and crafts session was now a very positive feature of the home, with people’s art work being displayed in the corridors and communal areas of the home. However, this was currently limited to weekdays only and people expressed being bored at other times, especially those who could not leave the home without family or staff supervision. The manager discussed plans to extend the activity coordinators hours to cover evenings and weekends.

We found that the home was now meeting the requirements of the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Assessments were being carried out of people’s capacity to make decisions. Where people lacked the ability to make a decision about living at the home or when restrictions had been placed on them in their best interests we saw that appropriate application had been made for a DoLS assessment. Staff had received training in this area.

Measures had been put in place to improve the running of the service. Staff meetings, unit meetings, supervisions and the newly developed training matrix were now being monitored by the manager.

The home had developed a more robust quality assurance system. However this had yet to be embedded into the running of the service in a way that identified the issues we had found and continued to find at this inspection.

We saw improvements in most areas of concern highlighted at our previous inspections. However we felt that sustaining and building on these improvements was crucial to offering people a consistently good level of care and support. This would require commitment from the provider in appointing a registered manager and to offer support to the staff team so that they provide an effective service. This is concerning given that we found new breaches and one continuing breach relating to people’s nutrition. The registered provider gave us assurances that every effort was being made to secure a registered manager.

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