Archived: Link House

At the last comprehensive CQC inspection of this home in September 2016 we found the provider to be in breach of two of their legal requirements. We therefore rated the service ‘Requires Improvement’ overall and for the two key questions, ‘Is the service caring and well-led?’ This was because the service did not have suitable arrangements in place to ensure people were always treated with dignity and respect and management oversight and scrutiny was effectively implemented.

We undertook a follow up focused inspection in February 2017 and found the provider had followed their action plan to improve and met their legal requirements. However, we did not change the service’s overall rating at the time because we wanted to be sure they could sustain these improvements over a longer period of time.

At this comprehensive inspection we found the service continued to make the necessary improvements. We saw action continued to be taken to ensure staff received specific guidance and training so the remained aware how to treat people with dignity and respect, particularly during mealtimes. In addition, we saw the provider continued to have appropriate arrangements in place to monitor the quality and safety of the service people received. This helped managers and senior staff check people were consistently experiencing good quality care and were quick to address any issues these governance audits identified. We have therefore improved the service’s overall rating from ‘Requires Improvement’ to ‘Good ‘and for all five key questions, ‘Is the service safe, effective, caring, responsive and well-led?’

The service had a registered manager who had been in post for a year and a half. A registered manager is a person who has registered with the Care Quality Commission (CQC). Registered managers like registered providers are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had a positive impact at the home and was highly regarded by people living there, relatives and staff.

People living at the home and visiting relatives told us they were generally happy with the service provided at Link House. We saw staff looked after people in a way which was kind and caring. Our discussions with people living in the home and their relatives supported this.

There were robust procedures in place to safeguard people from harm and abuse. It was clear from comments we received from staff they were familiar with how to recognise and report abuse. The provider assessed and managed risks to people’s safety in a way that considered their individual needs. Staffing levels appeared to be adequate. The premises and equipment were safe for people to use because managers and staff routinely carried out health and safety checks. The home looked clean and no infection control or food hygiene issues were identified. Arrangements for managing medicines safely had improved in the last six months and the number of medicines errors or near misses had been significantly reduced as a result. Staff recruitment arrangements were robust for new staff. However, the provider does not have a policy for renewing Disclosure and Barring Service (DBS) checks for existing members of staff. We discussed this issue with senior managers who agreed to look into this matter at provider level.

People said Link House was a homely and comfortable place to live. Bedrooms were personalised and the building was well-maintained. We saw the provider had made some recent changes to the environment to make it more suitable for people living with dementia. However, we found no consistency in relation to the pictures, photographs or signage that were being used to help people identify their room. We discussed this matter with the registered manager who agreed to ask people living in the home, or those acting on their behalf, how they might make it easier for people to identify rooms that were important to them.

Staff received appropriate training to ensure they had the right knowledge and skills needed to perform their roles effectively. People were supported to eat and drink enough to meet their dietary needs. People on the whole said they liked the quality of the meals they were offered. Managers and staff were aware of their duties under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff sought people's consent before providing any care and support and followed legal requirements when people did not have the capacity to do so. They also received the support they needed to stay healthy and to access health care services.

We observed staff providing personalised care to people which was tailored to their individual needs and wishes. Each person had an up to date and person centred care plan, which set out how their care and support needs should be met by staff. These were reviewed regularly. Staff communicated with people using their preferred methods of communication. This helped them to develop good awareness and understanding of people's needs, preferences and wishes. Staff were also knowledgeable about people’s backgrounds and cultural heritage. Staff encouraged people to actively participate in meaningful leisure activities that reflected their social interests and to maintain relationships with people that mattered to them. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. When people were nearing the end of their life, they received compassionate and supportive care.

People were given choices about most aspects of their daily lives. However, we also received some mixed feedback from people about the choice of food they were offered at mealtimes. Staff supported people to choose their meals they wanted to eat the day before, which meant people might not remember the meal choices they had made. We discussed this issue with the managers who agreed to review how they supported people to make a real informed choice about the meals they ate.

People and relative’s felt comfortable raising any issues they might have about the home with managers and staff. The service had arrangements in place to deal with people’s concerns and complaints appropriately. The provider routinely gathered feedback from people living in the home, their relatives and staff. The provider also worked in close partnership with external health and social professionals and bodies. It was evident from the registered managers comments they understood their registration responsibilities particularly with regards to submission of statutory notifications about key events that occurred at the service.

We undertook this focused inspection on 28 February 2017. We checked the provider had followed their plan and made the improvements they said they would to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Link House on our website at www.cqc.org.uk

Link House is registered to provide accommodation and personal or nursing care to 52 older people. The service specialises in caring for older people living with dementia. At the time of this inspection there were 37 people using the service.

The service is required to 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The previous registered manager left the service in December 2015. A new permanent home manager was appointed in August 2016 and at the time of this inspection was waiting to hear the outcome of their registered manager application to CQC.

At this inspection we found the provider had taken the action they said they would and now met legal requirements.

Training and support had been provided to all staff to ensure people were treated with dignity and respect, particularly during mealtimes. Senior staff monitored staff were putting into practice what they had learnt through unannounced spot checks. They shared their feedback with all staff to enable them to reflect on their working practices and further develop in areas which still needed improvement. We saw interactions between staff and people had improved. We observed the lunchtime meal and noted staff maintained regular dialogue and communication with people throughout the meal. Staff who were supporting people to eat did this in a dignified and respectful way.

The home manager remained focussed on achieving identified actions in the service improvement plan. They had regular meetings with the operations manager who in turn met regularly with senior managers at provider level to update them about progress being made to meet improvement targets and objectives. In this way, there was clear accountability and scrutiny at all levels for ensuring the service continued to work towards making improvements that were needed.

Provider level support for the service with regard maintenance issues had improved. The operations manager held weekly meetings with the maintenance department to check these issues were being progressed and that there were clearly stated timescales for when issues would be completed and resolved.

Link House is registered to provide accommodation and personal or nursing care to 52 older people. The service specialises in caring for older people living with dementia. At the time of this inspection there were 41 people using the service.

The service is required to 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The previous registered manager left the service in December 2015. A new permanent home manager had been appointed in August 2016 and was in the process of submitting the appropriate registered manager application to CQC.

At this inspection we found the provider had yet to make and sustain improvements in areas of the service we identified concerns with at our last inspection. We observed instances during the lunchtime meal experience when people had not been treated with dignity and respect by staff. We found that although the service offered a range of activities at the home, people said, and we saw, there was still not enough done to engage and stimulate people, particularly on the middle floor of the home.

There had been a change in leadership at the home and at provider level since our last inspection. This meant the service did not have continuous and consistent senior management oversight until recently, to ensure required improvements were made following our last inspection. There was a new improvement plan for the service based on a senior management review of the home in August 2016. Recent changes to the senior management structure meant there was better scrutiny and challenge at provider level to ensure required improvements would be made. However it was too early to assess the effectiveness of the plan to judge how this contributed to improvements in the quality of care and support people experienced.

There was provider level support available to the home manager to ensure the service was well managed. But one aspect of this support was not as effective as it could be. The home manager was not informed when maintenance issues they reported would be resolved. This meant they could not give the necessary reassurance to people that these were being addressed. The provider was planning to make improvements to the storage of medicines at the home. But we saw no plan or timescales for when this would happen. This did not assure us the provider would take action to undertake this improvement. Senior managers said they would take action to ensure timescales were clearly notified for when intended improvements would be made.

We found two breaches of regulations during the inspection. These were in regards to treating people with dignity and respect and good governance. You can see the action we have told the provider to take with regard to these breaches at the back of the full version of this report.

Some aspects of the environment were not supportive of people living with dementia. For example there was a lack of signage around the home that could have assisted people to orientate themselves around. This was being addressed at the time of this inspection by the home manager who was taking action to improve current signage in the home. However, people said Link House was a comfortable and safe place to live. The premises and equipment were regularly serviced and checked to ensure these did not pose unnecessary risks to people. The environment was free of hazards that could pose a risk to people’s safety. Risks to people’s health, safety and wellbeing had been assessed. Plans were in place to instruct staff in how to minimise these risks to keep people safe. Staff knew what action to take to ensure people were protected if they suspected they were at risk of abuse.

Staffing levels were planned based on the number of people at the home and their level of dependency. We saw staff were available to support people around the home when needed. The provider’s recruitment procedure was followed and appropriate checks were undertaken on staff of their suitability and fitness to work at the home. Staff received appropriate training and supervision to support them in their roles.

At this inspection we found improvements had been made to people’s care records. Staff now had access to up to date information about how to support people. People’s care plans reflected their choices and preferences for how support should be provided. Where people lacked capacity to make specific decisions there was involvement of their representatives and relevant care professionals to make these decisions in their best interests. People’s care and support was reviewed monthly to check this continued to meet their needs.

Staff were knowledgeable about people's needs and how they wished for their support to be provided. They were encouraged to assist people to do as much for themselves as they could and wanted to do. Staff ensured people’s right to privacy and to be treated with dignity when receiving personal care was respected. People were supported to maintain relationships with the people that were important to them. Staff were welcoming to visitors to the home. Relatives and friends were free to visit when they wished and regularly invited to participate in social events at the home.

People were encouraged to eat and drink sufficient amounts to support them to stay healthy and well. Staff monitored people’s general health and wellbeing. Where they had any issues or concerns about this they took appropriate action so that medical care and attention could be sought promptly from the relevant healthcare professionals. People received their medicines as prescribed. These were stored securely. The provider followed current legislation and good practice for the safe management of medicines. We identified minor issues with recording and storage of medicines which senior staff were already aware of through their own audits and taking action to address.

People were aware of the change in leadership at the home. Some staff told us they felt listened to and their suggestions for how things could be improved were acted on. Staff said as the new home manager had only been in post in for a month it was too early to form an opinion about the effectiveness of their leadership skills.

Senior staff carried out a range of audits of the service to check the quality of care and support provided. The home manager took responsibility for making improvements to the service when these were needed. People and relatives could feedback their experiences and suggestions for how the service could be improved through various forums. Some people and relatives said that they did not always know when residents and relatives meetings took place. Senior staff said they would look at ways to improve how people were better informed about these. People knew how to make a complaint if they had any issues or concerns about the service. The provider had arrangements to deal with any concerns or complaints that people had in an appropriate way.

The service was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and conditions on authorisations to deprive a person of their liberty were being met. DoLS provides a process to make sure that people are only deprived of their liberty in a safe and correct way, when it is in their best interests, and there is no other way to look after them.

We spoke with people who used the service. Comments included 'we are lucky, it's lovely here', 'the staff are wonderful' and 'I have no complaints at all.' Some people were not able to express their views and so we observed the care provided. We saw that generally staff interacted with people in a respectful and sensitive manner. Where support was being offered it was done sensitively and without rushing. We saw that people where possible were asked for their consent to care and treatment. We also spoke with two family members of people who used the service and a district nurse who visited that day and we spoke with six members of staff. A relative said they 'couldn't be more pleased with the care.'

We saw that arrangements were in place to ensure there was good communication between different health professionals who were involved in people's care. There were adequate arrangements for the management of medicines. Suitable equipment was available and was routinely checked with an outside contractor.

Since our last inspection we found that action had been taken to address the lack of compliance with the regulations at the last inspection. Staff had been provided with adequate and suitable training to carry out their work effectively. In addition there were more effective systems in place to assess and monitor the quality of the service.

People we spoke with told us 'it's very nice here', 'the staff are very nice' and 'they are very good to me, I couldn't ask for better'.

People all had their own rooms with en-suite facilities. They told us that they had been able to bring possessions from home in with them to make them more personal. We saw that this included photographs and small items of furniture.

Most people said that they enjoyed the meals at Link House. They told us that they were always offered a choice and there were chocolate drinks and toast and jam available if they were still hungry.

When we visited we noted that the home was very clean and tidy and free from unpleasant odours.

On the day of the inspection there were some activities arranged, for those who wanted to join in. However, some people told us that they would like more to do. The Register Manager told us that this was being addressed.

We did raise some concerns about staff training, as not all training was up to date. This did not provide the assurance that all of the staff had the necessary skills to support the healthcare needs of the people in the home.

There was limited evidence available to how the views of people were monitored and used to influence future service provision.