Link House

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 1 breach of regulation in relation to the governance and managerial oversight of the service. Systems and processes were ineffective in assessing, monitoring and improving the quality of the service. Accident and incidents were not fully reviewed, and not enough action had been taken to address risks and mitigate any future recurrence. The provider and registered manager had not identified when people’s care plans contained conflicting information or when there was insufficient guidance in place for staff to support people. Audits had failed to identify the shortfalls in the medicines management or that water temperatures had exceeded the recommended temperatures. Leaders and the culture they created had not assured the delivery of high-quality care.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us they promoted a person centred culture, they led by example by ensuring the care they provided was in line with good practice, however we found they did not have a good understanding of equality and had not prioritised safe and compassionate care.

The provider had values in place which were displayed in the service and staff were informed of these through their induction. We found the providers values were not embedded in the service as we found these were consistently applied by staff when delivering people’s care and support.

Although staff told us that the leadership of the service was good, we found this was not always the case. Roles and accountabilities were not clear; staff did not comply with their responsibilities in relation to safeguarding people and raising concerns within their organisation or externally. Staff did not always fully document incidents. Staff and leaders did not always share concerns with relevant stakeholders.

Systems and processes in place had not identified the issues we identified during our assessment in relation to the culture which had impacted on people’s care. The provider’s quality audit had not identified the shortfalls we found during our assessment

Staff told us they felt able to speak up and raise concerns, however we found this had not happened when incidents of a safeguarding nature had occurred.

Processes to ensure staff understood their responsibilities to share concerns were not always effective. Staff had not shared concerns outside of the service, for example by raising safeguarding concerns with the local authority. The provider failed to identify the culture within the service. The provider had missed opportunities to learn from incidents, share learning with staff and implement improvements including ensuring staff understood their responsibility to share any safeguarding concerns.

Staff told us how the provider was accommodating with any flexible working arrangements.

The provider had policies in place to ensure staff were treated fairly with an inclusive approach. For example, the provider made reasonable adjustments to enable staff to carry out their role. The provider had a policy on equality and diversity.

Staff told us when incidents occurred, they documented them and left them for the manager to review. However, we found this was not always the case. Staff told us they felt the service was well led and the manager did their best.

There were ineffective processes to ensure that lessons were learnt, and improvements made. There was no oversight of accidents and incidents. There was not a clear system of how and where to report and document incidents. Incidents had not always been reviewed by the manager or provider to ensure appropriate action had been taken. When incidents occurred, care plans had not always been reviewed and updated to inform staff of any new concerns, potential triggers, or de-escalation techniques. There was no review of incidents to look for patterns and trends.

People told us they went out and also went on holidays, relatives also confirmed this. One person told us they would like to go out to a place that they enjoyed more often.

Staff and leaders told us they referred people to external agencies for support and guidance, however we found this had not consistently happened as we had to prompt a referral for 1 person during our assessment.

External professionals told us they prompted the registered manager to make referrals when they had identified this was required. External professionals also told us they were aware from their visits to the service people had been supported to access a place of interest and people had told them they were happy living at Link House.

Systems and processes in place were not always effective in identifying when external agencies should be contacted to ensure people received external agency support. We found that people had been referred when their health had deteriorated, however when people needed to be offered support around relationships this had not been identified.

Leaders did not demonstrate a good understanding of identifying and actioning continuous improvement in the quality of the service. We received mixed opinions from staff if learning from incidents and accidents that occurred in the service was shared. One staff member told us safety events were followed up and fed back on, however another staff member told us they had no knowledge of this.

When incidents occurred at the home, these were not always thoroughly investigated. There were not always records of any debriefs with people or staff in respect of these incidents and they had not been used in line with the provider’s policy to develop peoples care plans.