The Links

The Links is a purpose built residential care home providing personal and nursing care to up to 68 older people some of whom are living with a dementia. At the time of our inspection there were 66 people using the service.

People’s experience of using this service and what we found

Staff worked closely with people and their families to find innovative approaches to providing outstanding person centred care that reflected a person’s unique history, culture and diversity. We observed exceptional staff engagement that showed people were consistently put at the heart of the service. Social activities were inclusive, varied and representative of the diversity of people and the staff team at The Links. People received high quality care at the end of their lives with staff ensuring people and their families felt cared for and that everything to meet a person’s last wishes were achieved.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The service was exceptionally well led. Staff were highly motivated and able to share many examples of achieving exceptional, positive outcomes for people. A strong emphasis was placed on staff wellbeing and was reflective in the positivity and energy of the staff team. People, families and the staff team were engaged in the service and able to be involved in events that were inclusive and reflected the diversity of both people and the staff team. Quality assurance systems and processes had been effective at sustaining outstanding standards with innovative ideas being researched and trialled to continually ensure best practice.

People felt safe. Staff understood their role in recognising and reporting any concerns of abuse or poor practice. People had their risks understood and agreed actions to mitigate any avoidable harm were being carried out, monitored and regularly reviewed. People had their medicines administered safely. There were enough staff with the right skills and experience to meet people’s needs. Recruitment practices were robust ensuring staff were suitable to carry out their roles.

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

Rating at last inspection

The last rating for this service was outstanding (published 10 October 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

Infection, prevention and control (IPC) policies and practices were in line with government requirements and reviewed to reflect any changes in guidance. IPC audits took place frequently, identified areas that required improvement and monitored and reviewed actions identified.

People were supported by staff that had received IPC training and had their competencies regularly checked. Personal protective equipment (PPE) was in good supply and we observed it being used correctly.

People, and the staff team, were participating in both the testing and vaccination programmes. Where staff were hesitant about vaccinations, they had an opportunity to meet with a BUPA pharmacist to discuss their individual situation.

Visitors to the home needed to make an appointment, were met on arrival by a member of staff, guided through the process of an on-site rapid COVID-19 test and the wearing of PPE, and had a temperature and symptom check list completed. An area, with its own external access, had been created as a safe visiting space. This enabled visitors and the person to be separated by a screen and use an intercom. People were also supported to keep in touch with family and friends via telephone and video calls.

Environmental changes had included relocating the staff room to a larger space so that staff were able to social distance during their breaks. In communal areas chairs and tables had been re-arranged to provide some distance between people. The home was clean, and equipment was in good repair. Cleaning schedules had been enhanced in response to the pandemic and included additional cleaning, particularly of regular touch points such as door handles and handrails.

Staff were aware of people who were self-isolating, including the need to reduce the risk of social isolation, ensuring extra visits to their room and time spent with them. People had their communication needs understood, including additional difficulties due to staff wearing PPE. One person was hard of hearing and an amplifier had been purchased to aid their hearing. People were supported to access the community. We observed one person going out to a local shop and they had been provided with PPE.

The Links is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Links was registered with a new provider in January 2017 and this was therefore the first inspection of the service since this took place.

The Links is a purpose-built home and is registered to accommodate a maximum of 68 people who require either nursing or personal care. Accommodation is provided over three floors each of which is an individual unit with its own communal areas and equipment. There were 51 people living either permanently or temporarily at the home when we inspected. The service specialises in providing care to people living with dementia.

The service had a registered manager. 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 and their visitors were very positive about the care that was provided at The Links. They were also full of praise for the staff. Many people gave us instances of exceptional care they had received or told us about occasions where staff had gone the extra mile to ensure people continued to live fulfilling, happy lives. Visitors valued the relationships they and their loved ones had with the staff team, and told us they always felt welcome. People’s independence was promoted as far as possible and their choices were respected.

Staff were a highly motivated team who demonstrated their commitment to providing high quality, individualised care to meet people’s preferences and needs. There was a very strong emphasis on the provision of activities that were meaningful to the people living in the home. This meant that people were supported to pursue interests and hobbies that were important to them. Activities were continually evaluated to ensure that they remained appropriate to people’s needs and individual preferences. People were able to access the local community either independently or with support. The registered provider encouraged community involvement and invited various local groups into the home on a regular basis.

Staff spoke positively and passionately about working at The Links. They told us that common aim for everyone was to provide a high-quality service to people in whatever role they undertook. They told us they felt very well supported by the management team who were always hand and, although supernumerary, always willing to lend a hand and work as part of the team.

Staff were well trained and had the skills to meet people’s needs. Managers had ensured that appropriate and regular training and supervision was available for all staff. This had included a virtual reality experience to give staff a real-life perspective of what it is like to live with dementia. Staff had all learned and reflected on the experience and were very clear about how highly it improved their understanding of living with dementia and changed how they supported people in a positive way. Staff also told us how they had worked hard to develop their skills to ensure that effective end of life support was available should people require it. This included supporting people to remain comfortable, dignified and pain-free as well as supporting any family or friends.

Activities staff in particular went to great lengths to understand people’s hopes and wishes and creative ways were found to enable people to live full lives. People were encouraged to do things they enjoyed and found meaningful, and this included social activities based on people’s interests. People were encouraged to continue to pursue hobbies and interests that they had before moving to The Links. This had included encouraging and supporting people to attend local events, take various trip including going out on boats, and spending time with a group of local motorbike enthusiasts.

There were sufficient staff on duty with the right skills and knowledge to provide the care and support people needed. The registered manager explained that staffing levels were based on people’s needs which were kept under constant review and that the number of staff on duty could easily be adjusted for either temporary or permanent reasons. Staff were recruited safely; checks were undertaken before they started work to ensure they were suitable to work in a care setting.

People’s care and support needs were assessed and planned for in detail prior to moving to The Links and through an ongoing review process. People and, where appropriate, their relatives, were encouraged to be involved in these processes. Staff knew people very well and understood their care needs and preferences. They spent time with people, both during care tasks and at other times. Care and support was not rushed and we observed staff working at the person’s pace.

Risks were assessed and managed pro-actively. The environment had been designed, based on research evidence, to promote the independence and wellbeing of people who lived with dementia. People were supported to take risks to maintain their independence as far as possible, for example, if they could walk they were encouraged to do so. Some people were on occasion reluctant to accept support with care, which could cause them to become distressed when staff attempted to assist them. The service had taken advice from specialist healthcare professionals. This had reduced the frequency of behaviour that challenged others.

Staff understood their responsibilities for safeguarding adults, including recognising signs of abuse and how to report any concerns and to whistle blow. Medicines were stored and managed safely, and were administered as prescribed. The premises were well maintained, with regular health and safety checks and up-to-date servicing. People were protected from the risk of infections by staff who ensured that the environment was kept clean and infection control procedures were followed.

People’s rights were protected because the staff acted in accordance with the Mental Capacity Act 2005, including the deprivation of liberty safeguards. Where people could give consent to aspects of their care, staff sought this before providing assistance. If there were concerns that people would not be able to consent to their care, staff assessed their mental capacity. Where they were found to lack mental capacity, a decision was made and recorded regarding the care to be provided in the person’s best interests.

People were supported to maintain a balanced diet and to have plenty to drink. People’s weights were monitored and appropriate action taken if people were identified as being at risk of malnutrition or dehydration. People had access to healthcare services and were supported to manage their health.

Lessons were learned and improvements made when things went wrong. Concerns and complaints were seen as an opportunity to bring about improvement. The registered manager and their team exercised their duty of candour, keeping people and where appropriate their relatives informed about what had happened as the result of an accident or incident.

The service operated openly and transparently, working cooperatively with other organisations to ensure people were safe and received the care and support they needed. The service had a clear management structure, with an established registered manager. They and other members of the management team worked closely with staff, frequently observing and providing care. People, visitors and staff were confident in the leadership of the service.

People and visitors were asked for their feedback about the service they received through regular surveys, meetings in the home and a suggestions box. People told us they felt listened to and that their views did influence how things happened.

There were systems in place to monitor the safety and quality of the service. This included the use of audits and surveying the people who used the service and their representatives.

The Links is a care home for up to 68 people. It is a purpose-built home that specialises in caring for people who are living with dementia. Accommodation in single, ensuite bedrooms is mostly arranged over the ground, first and second floors. Nursing care is provided on the first and second floors. There are six additional rooms on the third floor. There are two passenger lifts to assist people to get to the upper floors. When we inspected, there were 45 people living there.

The home is required to have a registered manager. 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. There has not been a registered manager since November 2015. The current home manager has applied to register as manager.

At the last inspection in December 2014 we identified breaches of the regulations and required the provider to make improvements to: the way they assessed and monitored the quality of the service, procedures for ordering and recording medicines, recording of consent and dietary needs, staff training, pain assessment, and care planning. This action has been completed.

Additionally, at our inspection in December 2014 we identified areas where improvements could be made. These related to dementia-friendly signage and arrangements for choosing meals. These improvements have been made.

People received the care and support they needed from staff who understood their care needs. They had a choice of food and snacks and drinks were available between meals. Their dietary needs were met. People’s health needs were monitored and if necessary referrals made to other health care professionals such as GPs.

People were treated with kindness and compassion and staff respected their dignity. Staff worked within the principles of the Mental Capacity Act 2005, wherever possible obtaining people’s consent to their care and respecting people’s choices. People and their relatives were involved in choices and decisions about care. Where people did not have the mental capacity to consent to particular aspects of their care, staff followed the correct processes to make decisions about the care in the person’s best interests.

People and their relatives were confident that people were safe at the home. Medicines were stored and managed safely. Staff understood how to keep people safe and how to report accidents, incidents or concerns. They felt confident in raising concerns with the management team. There were sufficient appropriately qualified and skilled staff on duty. The appropriate checks were made before people started working at the home to ensure they were suitable to work there.

There was a programme of regular checks and audits to ensure that care remained safe and effective and to help bring about improvements.

The home had a positive culture that was person-centred, caring and friendly. People, relatives and staff were proud of the home. People and relatives had regular opportunities to feed back their views about the home and quality of the service they received. There had been a significant turnover in staff following the change of manager during 2015. Most staff described morale as good, and expressed confidence in the current management. Staff were aware of the whistleblowing policy and felt that they could raise any concerns. They were supported through regular supervision and training. We observed that staff were calmer and more confident than they had appeared previously.

There was no registered manager at the time of our inspection, although the acting manager was present throughout.

The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full 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 a summary of what we found.

Is the service safe?

People were cared for, or supported by, suitably qualified, skilled and experienced staff. However, appropriate checks were not always undertaken before staff began work. One member of staff had started working at the home before they had Adult First barred list clearance from the Disclosure and Barring Service.

We saw a person in bed with bed rails raised. A bed rail risk assessment completed when the person was admitted to the home identified no risks that might make bed rails hazardous to use, such as episodes of confusion and agitation. However, this conflicted with a recent continuing health care funding care plan, which identified that the person 'often tries to climb over bed rails', putting them at risk of injury.

Falls were not always appropriately followed up, which meant that people were at risk of further falls. Moving and handling care plans for people with a history of falling did not address how staff should support them to move safely from the floor when they had fallen.

Wound care plans and records for three people whose files we looked at were not complete, which meant that their welfare and safety could not be ensured.

One person's medicines were sometimes disguised in a spoonful of food. There was no record on file of a best interest decision regarding this. There were no written instructions from a pharmacist to ensure the covert administration was safe.

We saw a stair gate across someone's doorway. A member of staff told us that this was to keep the person in their room. The person's care plan contained no reference to the gate, and no record of the person's consent, or a mental capacity assessment and best interest decision, for using the gate.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS), which apply to care homes. The manager confirmed that DOLS had not been authorised for anyone living at the home. They were aware of a March 2014 Supreme Court judgement about DOLS and told us that, in the light of this, they still needed to make applications for those people who may have been deprived of their liberty.

Is the service effective?

The people we spoke with said there were a range of activities on offer if they wanted them.

People's care records showed that they had access to external professionals when required. For example, one person had been referred for a wheelchair assessment, and had also been seen by a physiotherapist who advised how the person could be positioned comfortably and safely. A visiting GP told us that a doctor from their surgery visited the home regularly and that staff were always well prepared for their visits. They said that staff requested visits from the doctor when people needed this.

Is the service caring?

People spoke positively about the staff. One person said of the staff, 'They're polite, they're thoughtful, they're caring.' Another person told us, 'They treat me like I am an adult and an important one. They are like this with everyone, not just me. I can honestly say the staff have been brilliant.'

We spent time observing people in communal areas in different parts of the home, including a structured observation of the lunchtime period on the first floor, which accommodates people with dementia. There were many instances where staff attended to people's needs in a kind and caring manner. We observed that staff spent time reassuring and supporting people, responding quickly to requests for help and offering drinks frequently.

However, during lunch on the first floor we saw that a care worker failed to treat someone attentively and respectfully and in a way that met the person's individual needs. For 20 minutes we observed the care worker assisting the person to eat their meal, at the same time as completing paperwork. The staff member did not interact with the person. At one stage they commented to a colleague, over the person's head, that the person had had their hair dyed. Earlier in the day we had spoken with another care worker, who told us about another person, 'I let him have tea and toast in bed as he was a good boy.' This indicated a lack of respect for the person's adulthood.

Is the service responsive?

The people we spoke with were positive about their experiences at the home and said there were a range of activities on offer if they wanted them. One person told us, 'They come any time, day or night, if you need them' They see if you need help.'

The records for two people who had recently moved into the home did not contain completed assessments and care plans. This meant the people were at risk of receiving unsafe or inappropriate care that did not meet their needs.

Care plans contained insufficient detail about how staff could recognise signs of pain in people who might not be able to say they were in pain. Pain assessment tools were not routinely used, even where people had cognitive impairments.

Is the service well-led?

The provider did not have an effective system to regularly assess and monitor the quality of service that people receive. Quality assurance processes had failed to identify or to address prior to this inspection, the shortfalls we found with the delivery and recording of people's care, to ensure that the service complies with legislation. The acting manager informed us at the start of our inspection, 'You won't find fault in our personal care. You will find fault in our records.'

On the day of our inspection there was no registered manager in place. The manager told us they had applied to register.

We spoke with six of the 46 people living at the home. One person said, "I get everything I need. It is marvellous here ' wonderful'. Another person told us, 'It's a lovely building' and 'The carers are very good'.

We also spoke with two relatives who visited their family members regularly. One said, "I'm consulted on everything'. They told us staff anticipated what their family member needed, as the person was not able to communicate verbally. The other expressed their confidence in the care their family member received: 'I could go away on holiday and not worry'.

In addition, we observed care workers supporting people in communal areas, spoke with the manager and six staff who provided care, and looked at the provider's records, including records of care.

Care and treatment was not always planned and delivered in a way that ensured people's safety and welfare. This was because care was not always planned to meet people's assessed needs. Additionally, the care people received did not always reflect the needs identified in people's care plans.

As this inspection was about record keeping we did not speak with people who lived at the home. We spoke with two members of staff during the visit.

We looked at four care plans and other records for the people who lived at the home.

At this inspection we found people were protected from the risks of unsafe or inappropriate care and treatment because information about them was mainly complete and accurate.

The majority of people living at the home had dementia. Therefore, we used a number of different methods to help us understand the experiences of some people using the service.

We saw that people were relaxed with staff and responded positively when staff spoke and spent time with them. A member of staff we spoke with told us, 'People seem calm and happy'. Another member of staff we spoke with said, 'It's a nice relaxed, homely environment'.

We found that people's needs were assessed prior to moving into The Links and that care plans were person centred and regularly reviewed. One individual we spoke with told us that they were cared for well by staff. A relative we spoke with said the care people received was, 'Brilliant'.

There were enough qualified, skilled and experienced staff to meet people's needs.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

People who use the service, their representatives and staff were asked for their views about their care and treatment and these were acted on.

People were not fully protected against the risks of unsafe or inappropriate care because some records that the home kept about them were not completed or accurate.