This comprehensive inspection took place on 4 September 2018 and was unannounced.

The last comprehensive inspection took place on 22 and 23 June 2017. The service was rated requires improvement in the key questions, ‘is the service safe? and ‘is the service well-led?’ We found one breach of regulations relating to good governance. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when they would improve the key questions of ‘Is the service safe?’ and ‘is the service well-led?’ to at least good. At this inspection we found the provider had not met the regulation or improvements we had asked them to make.

The Links is a care home that provides personal care and support for up to six people with mental health needs. People in care homes 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. At the time of our inspection there were four people living at the service.

The person who owns the home is registered as an individual and they manage the home. Therefore, the home does not require 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.

During the inspection we found the provider did not always have robust risk assessments and risk management plans in place to minimise risks to people and others. Nor was there evidence of reviews to monitor and update risk assessments.

Staff rotas were not completed and safe recruitment procedures were not followed to ensure only suitable staff were employed to work with the people using the service.

Medicines were not managed safely as there was a lack or PRN (as required medicines) protocols, medicines administration records were not correctly signed, administration guidelines for some medicines were not in place for staff and only one staff member had completed medicines competency training.

People's dietary and health plans did not always have clear guidelines for how to support their dietary or nutritional needs and we saw one person’s care plan was not followed so their nutritional needs were met as planned.

The principles of the Mental Capacity Act (2005) were not always followed as staff did not have an understanding of the Act. Consent to care forms were either absent or generic and not decision specific.

The provider did not keep a training data base or audit and had not identified when staff training was out of date. We only saw one supervision record for each staff member since the last inspection and only one staff member had completed an appraisal which meant staff were not always being supported to develop the skills necessary to undertake their role effectively and competently.

The provider was only able to show us the initial assessment of one person’s needs. People’s care plan profiles were not always completed or person centred and they lacked dates and signatures. None of the files recorded end of life wishes.

The language used in records was not always appropriate for the service user group.

The provider did not have effective systems in place to monitor, manage and improve service delivery to improve the care and support provided to people and therefore concerns identified at the inspection were not picked up earlier by the provider. They had also not addressed the areas that we identified at out last inspection, as needing to be improved.

The provider had procedures in place to protect people from abuse. People using the service told us they felt safe and staff we spoke with knew how to respond to safeguarding concerns.

There was an infection

The inspection took place on 22 and 23 June 2017and was unannounced.

The last inspection took place on 21 February 2017, at which time we issued the provider with two warning notices requiring them to make improvements by 1 May 2017. We found breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to, person centred care, safe care and treatment, safeguarding service users, fit and proper persons employed, staffing and good governance. At the inspection of June 2017, we found the provider had made improvements to meet all of the regulations except for good governance where we found they had not done enough to fully meet the regulation.

The Links is a care home that provides personal care and support for up to six people with mental health needs. At the time of our inspection there were five people living at the service.

The home is owned by an individual who is also the 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.

During the inspection, we found that although the provider had made some improvements to their data management systems and record keeping since our inspection in February 2017, we judged they had not fully met the requirement.

People using the service were at risk because the provider did not always follow safe recruitment practices. We saw one staff file where the care worker was also working for another care agency. At the time of the inspection, the provider had not sought a reference from the care agency, which meant the provider had not checked that the care worker was suitable to work at the service. However, after the inspection the provider produced evidence they had received the reference from the care agency confirming the person’s suitability to work at the service.

Action had been taken to minimise the risk of people smoking in the service. People’s risk assessments and risk plans had been updated and provided guidelines for managing risk.

Medicines were administered safely, however the medicines policy did not contain guidance for administering PRN [as required] medicines. No one using the service was receiving PRN medicines and the registered manager said they would add PRN guidance into the medicines policy.

The service had procedures and policies to keep people safe and care workers knew to report any concerns to the registered manager. The provider had safeguarding and whistleblowing policies and a lone working assessment.

There were sufficient numbers of staff to meet the needs of people using the service.

The provider carried out a number of environmental safety checks so people lived in an environment that was safely maintained.

Care workers received an induction, supervisions and appraisals to develop their professional skills and to help them meet people’s need effectively. Training was reviewed in supervision and care workers were required to complete annual training in identified areas so they developed the skills required to care for the people they supported.

The provider was working within the principles of the Mental Capacity Act (2005) and care workers understood the need for people to consent to their care. However not all people’s consent to care statements were signed to indicate they had agreed to their care and support.

People using the service had a choice of meals and access to the kitchen whenever they wanted it.

We saw evidence that people were supported to maintain good health and access healthcare professionals as required.

People using the service indicated they had positive relationships with care workers and they were supportive. People had the opportunity to have one to one discussions in key workin

The inspection took place on 21 February 2017 and was unannounced.

The last inspection took place on 2 and 3 August 2016 at which time we found breaches of regulation regarding safe care and treatment, fit and proper persons employed, staffing and good governance. The provider had begun to make some improvements but not enough to fully meet the regulations as required.

The Links is a care home that provides personal care and support for up to six people with mental health needs. At the time of our inspection there were five people living at the service.

The home is owned by the person who is also the 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 using the service were at risk because the provider did not always follow safe recruitment practices. We saw staff files without references, Disclosure and Barring Service (DBS) checks that had not been viewed by the manager and a lack of application forms, which meant people employed by the service might not have been suitable to work there.

The service did not have robust risk assessments for people smoking in their rooms. There was not a record of room checks as directed in the risk management plans and people did not have personal emergency evacuation plans in place. Other risk management plans did not reflect people’s current situations and were not always effective.

The provider lacked systems to monitor the quality of the service and to identify if the needs of people using the service were being met effectively and safely. When we inspected the provider was not undertaking any checks or audits. This included medicines stocks and therefore we could not be sure care workers were administering medicines correctly and safely.

Care workers had completed safeguarding training and said they would report any concerns to the manager but could not identify the types of abuse or who to contact outside of the service.

There was sufficient staff and care workers did not work more than 48 hours per week. However, the registered manager was working 70 hours per week. Additionally we were told that one care worker was sleeping in the lounge instead of in the office at night.

Supervision notes were very limited, there was no record of competency observations and care workers did not have appraisals so we could not be confident staff were receiving the support they needed to deliver care as required by the people using the service.

The service had not assessed people’s capacity to consent to care and treatment and care workers we spoke with did not understand the principles of the Mental Capacity Act (MCA) 2005.

People’s files were not always up to date with relevant information such as contact details.

Care plans were not always person centred or reviewed in a meaningful manner, therefore people were not involved in them and they were not always relevant to people’s current needs.

The service had very few structured activities and therefore we recommended that the provider review activity provision in line with the National Institute for Health and Care Excellence (NICE) guidelines.

People’s relapse plans for their mental health needs were comprehensive.

The provider had safeguarding and whistleblowing policies and a lone working assessment.

The manager understood their responsibility to report any abuse and when to make notifications to the local authority and Care Quality Commission.

People had a choice of meals and access to the kitchen whenever they wanted it.

People were supported to maintain good health and access healthcare professionals.

Staff responded to people in a caring and patient manner.

We found breaches of the Health and Social

The inspection took place on 2 and 3 August 2016. The first day of the inspection was unannounced and we told the registered manager we would be returning the next day.

The last inspection took place on 8 July 2015 at which time we found two breaches of regulation regarding staffing and safe care and treatment. The provider had made some improvements in these areas, however we identified further improvements were needed. The provider was recording incidents appropriately and had improved their induction process, however they still needed to register all staff to complete the Care Certificate on line and undertake annual appraisals for all staff.

The Links is a care home that provides personal care and support for up to six people with mental health needs. At the time of our inspection there were five people living at the service.

The home is owned by a person who is also the 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 were at risk because the service did not have suitable arrangements in place for people smoking in their rooms. Nor were there personal emergency evacuation plans (PEEPs) for people who used the service.

Safe recruitment practices were not always followed and staff worked long shifts which meant people could be at risk of being supported by unsuitable staff.

The registered manager said staff had supervision, appraisals and training but the lack of written evidence to support this meant we could not be sure staff were being suitably prepared for their roles with the required skills. The training files we saw indicated training was inconsistent as not all staff had up to date safeguarding training. No one had completed the Mental Capacity Act (MCA) 2005 training and staff had a poor knowledge of how to implement it. However, the registered manager understood their responsibilities under the MCA and there were no restrictions on anyone using the service.

The service lacked systems to monitor the quality of the service delivered to ensure the needs of the people who used the service were being met. We recommended the registered manager seek and follow advice and guidance from a reputable source regarding good governance in care homes.

People were supported to have enough to eat and drink and were able to access the kitchen whenever they chose to. However, People were not always satisfied with the quality of the food. We recommended that the provider review the food quality of the service.

The service had a safeguarding policy, most staff had attended safeguarding training and staff knew how to report safeguarding concerns. Risks to people’s safety and wellbeing had been assessed and we saw evidence of risk management plans that included steps to minimise risk and keep people safe. There were a number of regular maintenance and service checks carried out to ensure the environment was safe. Medicines were administered and stored safely.

People were supported to access health care services. Feedback from people who used the service and professionals indicated they had a good working relationship with the community mental health team.

People who used the service told us staff listened to them and their dignity and privacy was respected.

Four people had comprehensive care plans that reflected their choices and risk assessments that were regularly reviewed. However, one person’s file was incomplete and did not contain an assessment form, contact details or risk assessments.

People using the service, their relatives and staff were comfortable speaking to the managers.

The service provided accessible information on how to make a complaint.

We found breaches of the Health and Socia

This inspection took place on 8 July 2015 and was unannounced. At the last inspection on 13 June 2014 we found the service was not meeting the regulations relating to medicines management, requirements relating to workers, assessing and monitoring the quality of the service provision and notifications. At this inspection we found that overall improvements had been made in the majority of the required areas. We also found areas where new breaches were identified.

The Links is a care home that provides accommodation and personal support for up to six people, with mental health needs. There were five people using the service when we visited.

The home is owned by an individual who is also responsible for managing the service. A registered provider is a person who has registered with the Care Quality Commission (CQC). 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.

We found the service did not have arrangements in place for managing medicines when people were away from the home. We have recommended that the provider use best practice guidance to improve this area.

The system used by staff to record incidents did not ensure that incidents were monitored for any trends or patterns to help prevent them in future.

The provider did not have in place a formal appraisal or structured induction process for staff to follow, therefore staff were not being prepared and assessed for their role and their development needs were not reviewed.

There were enough staff on duty to make sure people received the care and support they needed. Appropriate checks were carried out for new staff to help protect people from the risk of being cared for by unsuitable staff.

Regular maintenance and service checks were carried out at the home to ensure the environment was safe.

The provider had arrangements in place to safeguard people against the risk of abuse. Risks to people were identified and management plans were in place that promoted people’s independence and safety.

Staff were aware of the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People told us there were no restrictions on their freedom.

People were supported to maintain good mental and physical health and had access to health care services as and when they needed them. Staff worked closely with the Community Mental Health Team about how to support a person’s mental health, so that people had good health outcomes.

The staff encouraged and supported people to eat and drink food that met their individual needs and preferences.

People were supported by caring staff who respected their privacy and dignity and promoted their independence. People were involved in decisions about their care, treatment and support needs.

People told us that if they had any concerns that they would speak to the staff if they needed to. They were confident the service would listen to them and they were sure their complaints would be fully investigated and action taken if necessary.

People, staff and healthcare professionals spoke positively about the provider and how they ran the service.

The provider regularly sought people’s views about how the care and support they received could be improved. There were systems to assess the quality of the service provided in the home. We have identified further areas that the service can improve and we have recommended that the provider use best practice guidance to develop this area further.

We found a number breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

During this inspection we met three people using the service, spoke with two healthcare professionals and three staff. The staff included the manager and two support workers.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found.

Is the service safe?

The service was not always safe. People’s needs were assessed and care plans were in place. The provider had made improvements to the management of people’s monies and there were no restrictions for people to access the kitchen. People's medicines were not being managed in a safe and appropriate way. Some improvements had been made to the checks that were carried out on staff prior to their starting work, however further improvements were required so that the arrangements for staff recruitment were more robust. The fire alarm system was not checked at regular intervals and fire drills had not taken place, therefore people were at risk because they did not know the procedure to follow in the event of a fire.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, the manager was aware of her responsibilities and had a good understanding of when an application should be made.

Is the service effective?

People told us they were happy with the service and were well cared for. People’s health and care needs were being monitored. People were supported by a range of different health care professionals to make sure that they received care in a joined up way.

Effective systems for assessing and monitoring the quality of the service provided to people were not in place and this meant that they were at risk of receiving inappropriate or unsafe care and treatment.

One healthcare professional told us “my client is very positive, we work together with the manager to resolve any concerns”.

People told us they were included in decisions about how their care and support was provided.

Is the service caring?

People told us the staff were kind and caring. We observed staff being polite and respectful towards people. One health care professional told us that they had been “amazed” at the progress their client had made at the service. Another said that their client had told them during a review meeting that they liked living at the service. Comments we received from people included “I get the right help, I’m in the right place” and “I like it here”.

Is the service responsive?

People told us they could speak with the manager and staff if they had any concerns. The staff responded to people’s changing needs. For example one person had been assessed for mobility equipment so that they could remain independent and this was now in place.

The two healthcare professionals we spoke with told us the manager listened to and acted upon any suggestions that they made to support people’s care and treatment. They told us the manager was in regular contact with them to keep them up to date with any changes in people’s needs.

Is the service well-led?

There was a registered manager at the service. She demonstrated a good knowledge of the people living at the home and their individual needs.

The healthcare professionals we spoke with told us the manager had a very good understanding of people’s mental health conditions and the best way to support them. Comments we received included “this is the longest placement that my client has had. I am very, very impressed they have done wonders with my client” and “I have no concerns at the moment, the manager knows what she is doing”.

The provider did not have an effective system to regularly assess and monitor the quality of service that people received.

At the time of our inspection there were four people using the service. During our inspection we spoke with three of them, one staff member and the manager, who is also the owner of the service. People who use the service said they generally enjoyed living at the home. They said the staff were caring towards them and we saw staff spoke with people politely and treated them with respect. People liked the food provided by the service, and we saw a variety of foods available for meal preparation.

Some people said that they felt restricted by the routines of the home, such as the kitchen opening times or not being able to use their computer, and there was no recorded evidence to support these practices.

Similarly, the support plans and risk management plans did not provide clear information about people’s needs or how they were to be supported by the service.

However, we found that people were put at risk where the provider did not carry out robust checks prior to the recruitment of new staff.

There were insufficient records relating to the people who use the service, staff and overall management of the service, which put people at risk of inappropriate care and treatment.