Linden Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We undertook this assessment as the home required improvement in 2 areas following our last inspection. We had also received information of concern following 2 incidents where people had been at risk of being harmed. We found 2 breach's of the legal regulations in relation to Safe systems, pathways, and transitions, and Infection prevention and control. Measures around medication were not robust. Care plans and audits were not accurate enough to ensure safety and identify areas for improvement. We have asked the provider for an action plan in response to the concerns found at this assessment and how they will embed improvements in practice.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most relatives told us any concerns about safety were listened to, investigated, and managed to ensure people’s safety. One relative said, “We are informed immediately if there are any accidents or falls even if not resulted in any injuries, excellent communication at all times.” However, one person told us that their relative had a fall and they were not informed saying “We feel the communication is sadly lacking.

Staff told us they could raise concerns with the senior managers and were confident their concerns or suggestions about people’s safety were listened to and acted on. Staff told us they were kept up to date following incidents and lessons learned

Some learning was evident from the previous CQC assessment. The quality of audits around environmental safety and maintenance were being carried out. However, we found the provider did not have a robust culture of safety and learning. Some safety issues were not always given top priority or learnt from which had exposed people to the risk of harm. Examples of this were admitting 2 people into the home without ensuring the environment and equipment were suitable and safe for them. One had fallen. No harm had come to the person, but work was needed to demonstrate how learning from incidents had achieved better outcomes for people and were being embedded into good practice.

People’s care was dependent on staff knowledge of their needs as we found not all care plans were completed in line with the timing in the policy. This means people are at risk of harm with staff not having a full understanding of their care needs. The Registered Manager didn’t always take professionals advice to make relevant referrals. Most relatives told us they felt the service liaised well with other organisations involved in their family member’s care and information was shared

The Registered manager advised us of close working with the Hospital teams to better support people with their admissions to the home. This enabled them to understand how their needs can be met with the community team and the home

The Local Authority said the Registered manager worked closely with them to complete their action plan and they responded well to advice and guidance.

We reviewed the records of 5 people who had arrived since 15th May 2024. No care records had been completed for them as a priority. An example of this was a person arrived 03 June 2024, and their care plan was not completed until 25 June 2024. This means that staff don’t have the required information to meet people’s needs and keep them safe. We were not assured the provider had established and maintained safe systems of care.

The Registered Manager had systems in place to monitor people’s health and wellbeing. However, we found care plans were not always being updated monthly as stated in provider’s policies. Examples of this were 1 person’s care plan being reviewed 30 March 2024 and then not until 18 June 2024.

Relatives mainly said family members felt safe and supported to understand and manage risks, people that we spoke to said they felt safe and supported to understand and manage any risks.

Staff mainly understood their roles in relation to safeguarding. Staff said people were made to feel safe. Staff received relevant safeguarding training as part of their induction. Information about current procedures and raising concerns about abuse was displayed throughout the home and on staff portal.

People appeared relaxed and comfortable in the presence of staff. We observed staff engage warmly and appropriately with them. We were not assured that there was enough staff to ensure people received safe care. Examples of this were observed on 17 June 2024 and 12 July 2024 where there was no member of staff in the conservatory or lounge areas. There were people in these areas who were reported to be a high risk of falls.

Peoples care plans were not consistently updated. An example of this was one care plan not updated since 12 April 2024. The registered manager had advised us the person needed 1 or 2 carers to support them. As this was not recorded anywhere. his meant the person was at risk of not receiving safe care and treatment. Depravation of Liberty Safeguarding (DOLS) were in place when needed, and best interests’ decisions had been made. However, the best interest decisions required improvements to ensure people's views were included and recorded. Mental Capacity Act (MCA) assessments were not always fully completed.

Relatives told us staff knew their family members well and kept them informed with updates about their wellbeing, including risks to their safety. Relatives were confident their family members were just as well looked after when they left the premises as when they were visiting. One said “My mother loves the staff, and they all seem to love her. This makes leaving her so easy.” However, most relatives we spoke to had not been involved in initial care plans and on-going reviews. Only 1 relative said they had been invited to relatives’ meetings in the past. None had been asked to complete feedback questionnaires.

Staff understood the need to read and follow people’s care plans and risk assessments. They told us that they understood safeguarding processes and how to speak up if they had concerns about people's care. They understood how to try and promote independence in people, whilst also keeping them safe. The registered manager told us they had made improvements to people’s personal emergency evacuation plans (PEEP's), and a recent comprehensive fire risk assessment had been carried out.

We observed activities taking place for mealtimes, moving and handling, and general care interactions between staff and people. Staff were generally responsive to people needs, carried out safe moving and handling practices, and demonstrated an understanding of individual likes and dislikes. We reviewed incident and accident reports and carried out further observational assessments of people. One person had a high number of incidents of agitated and aggressive behaviour. There was limited detail as to why this was occurring, so strategies had not been used to de-escalate people’s distress, find out what worked well and find a more positive approach to managing such incidents. Further analysis with regards to the causes of people becoming distressed or agitated, would ensure better understanding of people’s needs and how to manage risks to their safety in a more holistic way.

Each person had a set of individualised assessments and care plans. These were not all up to date, or had individual wishes recorded. People who had been identified as having a high risk of falls had sensor mats to alert staff if they move unsupervised. However, we found some risks to people that had not been identified. An example of this was a new person who moved to the home following a hospital discharge and had an unwitnessed fall. We saw no care plan in place or evidence that his identified needs had been considered and actioned. When the person fell, the appropriate health professional was contacted, but their recommendations of what the person needed to prevent further incidents were not actioned. Care plan assessments were not always consistent with the information they contained, and it was not always clear that recommendations had been considered. One person had different outcomes for pressure sore risks on assessments, and different descriptions of appetite. Care plan outcomes evidenced a high risk for pressure injury, but we observed the person to have no equipment in place, or evidence of further assessment. Staff advised us that nobody was on a special diet, however we saw records that differed in clinical records. We saw that people were on ‘healthy eating’ regimes but saw no evidence this had been discussed and agreed with them. We were not assured people were always protected from the risk of harm.

We spoke to 7 relatives and 6 advised us they were happy with the environment and though it was well maintained and cleaned. One told us the “Home was kept spotlessly clean and bedrooms and bedding always changed regularly”. One relative said, “We feel that his room could be better as we often smell urine when we visit”. People living at Linden Manor told us they felt it was clean and they had help to “make things tidy”.

Staff provided positive feedback about improvements made to the premises after the previous CQC inspection. We observed staff appropriately storing cleaning supplies, kitchen supplies, and moving and handling equipment. People's safety mats were in the right position, and checks had been made to ensure they were working. Staff understood the importance of being compliant with safely training such as fire training and spoke positively about the training they received.

We observed improvements in audits and maintenance logs, and changes which had been made to reduce the risks of scalding and harm from radiators and exposed pipes. Substances which could cause harm were locked away. We observed moving and handling equipment had been risk assessed and serviced, and improvements made to the use of slings. During our assessment we observed the floor in the main lounge being cleaned. Although yellow warning signs were in place, these might not have been understood by people in the lounge and caused a risk to people when they mobilised. We discussed this with the manager who advised us she would ensure this did not happen.

New systems, checks and audits had been introduced monitoring the safety and upkeep of the premises and equipment. Other safety checks included portable appliance testing (PAT), legionella testing, the fire alarm system and firefighting equipment. A manager walk around weekly audit was in place, which covered bedrooms, bathrooms, communal areas, kitchens, and general decor and furnishings. We were advised that a daily walk around also took place but was not recorded.

Feedback from people and their relatives about staff was positive. Almost all relatives told us there always seemed to be plenty of staff on duty, whatever time of day they visited. Comments included, “Usually enough staff about and my relative gets help quickly if she asks for anything. I used the pressure mat to get assistance when I visited, and staff responded immediately.” and another said her relative was “looked after well and she’s flourished since going into the Home. She says she loves the staff, and they seem to love her.” All the relatives we spoke to were confident staff had received the training they needed to care for people. A relative told us, ““Staff seem well trained in what they are doing and very patient with dementia residents. She’s got a pressure mat in her room, and we feel safe knowing the staff respond as soon as she tries to get up on her own.”

Staff mostly told us they thought numbers and skill mix of staff ensured people were receiving safe care. Comments included, “We used to have a staff problem but now it is settled,” and “It feels a bit short-staffed, but generally OK.” Staff confirmed they received the support they needed from senior managers to deliver safe care, including regular supervision and appraisal. New staff confirmed they had completed an induction program, and they were expected to complete mandatory training.

We saw records that a person had a fall from a wheelchair in the lounge. The provider was unable to explain how this happened. We observed staff being interrupted when they were dispensing medications, to help with other care needs. This increased the risk of medicine errors. During the assessment period, we became aware of an incident where a person fell and hit their head, necessitating a stay in hospital. The provider was unable explain how this happened to us or the emergency services who attended. There were inconsistencies in the care plan instructions of how the person should be assisted to transfer, for example from their bed to a chair. We were not assured the staff numbers and skill mix were always adequate to give people the care and support they needed and keep them safe.

The provider followed safe and effective recruitment practices, and staff were monitored for compliance with mandatory training. Staff received formal support with supervision, appraisal, and checks on their competency. Recruitment practices ensured staff were safely recruited and suitably experienced, to carry out their roles. The training matrix showed staff had completed a range of training, including dementia awareness. We saw evidence of compliance with training discussed in team meetings, and access to enhanced training if it was requested. The registered manager had appropriate training and experience and was supported by the senior leadership team with development. We observed staff working together effectively to provide safe care; however, we were not reassured they always did this when it was needed.

The home appeared clean, and staff were employed to carry out regular cleaning. Staff used personal protection equipment as required. Most people and their relatives mainly said that they felt it was clean throughout, one said “always a nice smell of wood polish”. However, another relative felt his relative’s room could be better as often smell urine when visiting. All the relatives spoken to say the staff all wore aprons and gloves when supporting with personal care or handling meals.

Staff did not raise any concerns about infection, prevention, and control (IPC) practices at the service.

Most Staff we observed demonstrated good IPC practices. Premises and equipment were kept clean and free from odours. The kitchen areas were clean and tidy. The food hygiene rating was a 4 (issued on 9 August 2023) However, there was a bag of dirty laundry placed on radiator in a corridor, and one person’s room had a dirty crash mat. This was cleaned when brought to the Registered Managers attention. A mop bucket with water was kept under the stairwell causing a potential trip hazard. On the 12 July 2024 we observed medication being administered directly into a person’s mouth without wearing gloves.

Staff were trained in infection prevention and control within their induction and were provided with relevant protective equipment when required. The service had a suitable policy in place.

We were not assured that peoples medicines and treatments were safe and met people’s needs, capacities and preferences. People were not enabled to be involved in the planning/updates of care plans with regards to self-medication as people were asked on arrival and this was not revisited. People did not consistently receive their topical medicines, one person had topical medicine on their care plan but not on carer duties, therefore it was not clear if people were always receiving their prescribed creams, this was brought to the attention of the RM and rectified. Numerous rooms had topical prescribed medicines in their cabinets with the cabinets unlocked with no risk assessments in place to consider whether this was safe. All relatives were happy with how their family member’s medicines were managed and felt they were kept informed of any changes. One family member said “My --- followed a religion and she did not believe in blood transfusions. The Home asked if I would give permission for her to have a transfusion and I refused on the grounds my --- would have refused if she had the mental capacity of doing so. They respected this decision and iron tablets have been given in place of this. I was pleased they respected my wishes.”

 The registered manager said as now auditing controlled drugs daily and MARS twice a month, errors are identified quickly, staff were aware medicines are audited. Staff were aware only seniors/care manager administered medicines.

People’s medication cabinets were unlocked in rooms containing prescribed creams. There were no risk assessments to determine whether this was safe and consider the risks to people. People’s medicines were not always managed safely. We observed a staff member giving people their medicines. Despite wearing a tabard saying not to be disturbed we observed the staff member being called away from giving medicines by other staff on two separate occasions. This increased the risk of medicine errors. Staff were observed given medication directly into the mouth of a person without wearing gloves. This causes a potential serious risk of cross infection with medications.

We were not assured medicines were being administered accurately, in accordance with prescriber instructions. Processes had not identified the risks we observed with the administration of medicines. We were not assured Care plans always reflect peoples current preferred way of taking medication as these are not reviewed regularly. A process was in place if people refuse to take their medication.