Link House is a ‘care home’. People living there receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate up to 52 older people across three floors, each of which have separate adapted facilities. The first floor specialises in supporting people with nursing care needs, whilst the ground and second floors support people with personal care needs. At the time of our inspection 32 people were residing at the care home, of which two-thirds were living with dementia.

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. W

We carried out a comprehensive inspection of this service on 28 September 2016 at which two breaches of legal requirements were found. The provider did not have suitable arrangements in place to ensure that people were always treated with dignity and respect by staff, specifically during mealtimes at the home. We also found this service had not had continuous and consistent senior management oversight to ensure required improvements were made. After the inspection, the provider wrote to us with a plan for how they would meet legal requirements in relation to these breaches.

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.

This inspection took place on 28 September 2016 and was unannounced. The last Care Quality Commission (CQC) comprehensive inspection of the service was carried out in August 2015. At that time we gave the service an overall rating of ‘requires improvement’. We did not find the provider in breach of regulations but we identified some aspects of the care and support people received had not been caring, there were not enough activities to stimulate and engage people and the quality of records maintained by the service was inconsistent.

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, peopl

This inspection took place on 6 August 2015 and was unannounced. The last Care Quality Commission (CQC) inspection was carried out in October 2014. At that time we found breaches in relation to care and welfare of people who used the service, respecting and involving people who used the service, staffing levels and supporting staff and assessing and monitoring the quality of service provision.

Link House is a care home providing accommodation and nursing care for up to 52 people. The home is split across three floors providing residential care, nursing care and care for people living with dementia. At the time of our visit, there were 49 people using the service.

The service had 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

During this visit we found the provider had taken action to make improvements that were needed to meet the five breaches we found at our last inspection. We found action had been taken to improve the continuity and consistency of staffing levels within the home so that there were enough suitably skilled and competent staff on duty on every shift. The provider had taken the decision to increase the numbers of staff needed to work in the home and was actively recruiting to new posts. Where new staff had been appointed there were robust checks carried out by the provider to ensure they were suitable and fit to work in the home. Staff now received regular training to support them in their roles and met regularly with their line manager to discuss their work performance and learning and development needs. They demonstrated a good understanding and awareness of how people’s care and support needs should be met.

There were systems in place to check and monitor the premises, and equipment within it, so that these did not pose risks to people’s safety. Regular maintenance of the home and equipment took place. The home was kept free of obstacles and hazards so that people could move freely and safely around. The provider had taken steps to redesign the home to improve the physical environment particularly for people living with dementia. However where there were identified risks to people due to their specific physical and mental health care needs we were not fully assured the information about these individuals was assessed and evaluated regularly to ensure plans to manage these were relevant and current.

Records were in place to record information about people’s food and fluid intake, to enable staff to support people who may be at risk of malnutrition and dehydration more effectively. People were supported to eat and drink sufficient amounts. However people had mixed views about the quality of food they ate which the provider was taking action to address. Where issues and concerns about people’s current health and wellbeing were identified, staff took action to monitor and record information as well as seek appropriate advice and support for individuals such as referral to their GP. Staff ensured people received their medicines as prescribed.

People told us they were safe at Link House. Staff knew how to protect people if they suspected they were at risk of abuse or harm. They had received training in safeguarding adults at risk and knew how and when to report their concerns if they suspected someone was at risk of abuse. People and their relatives spoke positively about the staff that cared for them. However we saw some instances where staff were not as caring as they should have been towards people they were supporting.

Staff knew how to ensure that people received care and support in a dignified way and which maintained their privacy at all times. Staff supported people, where appropriate, to retain as much control and independence as possible, when carrying out activities and tasks.

New care plans had been developed for each person using the service which now reflected their preferences and choices for how they wished to be cared for and supported. These plans gave guidance and instructions to staff on how people’s needs should be met. However the quality and accessibility of information about people’s care and support needs was variable. In some instances information about people’s current care and support needs was not kept in one place so that all staff had access to this. Some records contained out of date and obsolete information. Care plans had not all been reviewed monthly as the provider prescribed.

The home was welcoming to visitors and relatives. However people said there was not enough for them to do. We were aware action was being taken to improve the quality and range of activities within the home, particularly for people living with dementia but we saw instances where people were not stimulated or engaged by staff.

The registered manager demonstrated good leadership and used learning to drive improvement. There were now arrangements in place to regularly seek the views of people and their relatives about how the service could be improved. The registered manager ensured staff were clear about their duties and responsibilities to the people they cared for and accountable for how they were meeting their needs. If people had concerns or complaints about the care and support people experienced, there were arrangements in place to deal with these appropriately. Where concerns had been raised we saw these were dealt with proactively by the registered manager.

Regular checks were carried out by senior staff of key aspects of the service to monitor and assess the safety and quality of the service that people experienced. The registered manager was fully aware of current shortfalls in the service, particularly with regard the quality of people’s records and information about their care and support needs, and had taken appropriate action to address these.

Staff had received sufficient training in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) to understand when an application should be made and in how to submit one. 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.

This inspection took place on 14 October 2014 and was unannounced. At our last inspection on 24 July 2013, the service was judged to be compliant with all of the regulations that we inspected.

Link House is a care home providing accommodation and nursing care for up to 52 people. The home is split across three floors providing residential care, nursing care and care for people living with dementia. At the time of our visit, there were 49 people using the service.

The service requires a registered manager to be in place. 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. At the time of our visit, the service did not have a registered manager in place. There was a manager in post who had not yet completed the registration process and we will check to make sure this is done. This manager had recently returned from a four-month period of absence, during which other managers employed by the same provider had been covering the role.

We found there were not always enough staff to ensure people’s needs were met and the home used a high level of agency staff, which put people at risk of being cared for by staff who did not know them well enough to meet their individual needs. However, there were safe recruitment processes to protect people from the risks of being cared for by unsuitable staff.

The provider shared information on good practice with staff through meetings, memos and other communications. However, in the months before our visit staff had not received adequate support such as supervision and specialised training to help them meet people’s individual needs.

People had choices about what to eat and drink and the service catered for different nutritional needs. However, there was a lack of monitoring of food and fluid intake for people who were at risk of malnutrition.

People were not always involved in decisions about their care and their views were not taken into account when care was planned. However, people fed back that staff were kind, caring and compassionate although they did not always have time to engage people in meaningful conversations. Staff delivered care in such a way as to respect people’s privacy and dignity

We found at least one person was receiving care without a full assessment of their needs or a care plan, which meant they were at risk of receiving unsafe or inappropriate care. However, other people’s care was planned in response to a full assessment of their needs and this was regularly reviewed.

The service had clear processes for responding to complaints. However, people did not know how they could discuss their care and have their say and relatives agreed. The service was not carrying out any surveys, meetings or other methods of involving people in decision making about the way the service was provided.

Staff knew about their responsibilities in terms of the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). A number of applications to deprive people of their liberty were waiting to be made, but at the time of our visit the local authority had not yet been able to process these.

There were risk assessments in place and staff were aware of how to manage people’s individual risks. The provider had a system to monitor accidents, incidents and environmental risks. There were policies, procedures and systems in place for the safe storage and administration of medicines.

People had access to healthcare professionals to meet their needs when required.

Some people engaged in activities that were meaningful to them, although we found this area was lacking in terms of support for people living with dementia. People and their families said they would like more activities to be offered.

We recommend that the provider consider relevant guidance, such as that produced by the National Institute for Health and Care Excellence (NICE), about cognitive stimulation for people living with dementia.

There were systems in place to assess and monitor the quality of the service. Records showed that improvements had been made in several areas over the last year. Managers were aware of the shortfalls that we found and had an action plan to rectify them.

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

At our last inspection on 16th November 2012 we identified areas where the provider was not meeting the essential standards of quality and safety. The provider sent us an action plan to tell us how it would become compliant with the regulations. We carried out this inspection to review improvements and to check other aspects of the service. Since the last inspection we had been notified about the long term absence from the service of the registered manager and that they had subsequently resigned. We had been advised of the arrangements that had been put in place. The home was being temporarily managed by a registered manager from another home, whilst a new manager was being recruited.

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.

Link House provides both personal care and nursing care. The first floor accommodates people who may have dementia.

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.