CQC report explained · a residential care home
What the CQC found at Linden Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Linden Manor is rated Requires Improvement; inspectors found kind, personalised care but ongoing risks with safety checks, medicines and management oversight.
This was an unannounced inspection prompted partly by concerns about emergency care and to check whether earlier improvements had been made. Inspectors visited the home and spoke with people, relatives, staff and managers. They also reviewed care records, staff recruitment files and management records.
People told inspectors they felt safe and were treated kindly. There were enough staff, care plans were personalised, and people received support with food, healthcare, activities, communication and relationships. The home was clean and relatives said concerns were dealt with.
However, inspectors found that some risks had not been identified or managed well. These included risks linked to diabetes, exposed hot water pipes, medicines, moving and handling equipment, cleaning records and pressure-relieving mattresses. The systems used by managers had not found or fixed some of these problems.
The overall rating remains Requires Improvement, as do Safe and Well-led. Effective, Caring and Responsive are rated Good. The home has received Requires Improvement for the last three inspections.
Enough staff
Inspectors found enough staff to meet people's needs. Staff worked together to cover sickness and holidays, and regular agency staff knew people well.
“There were enough staff available to meet people's needs.” from the report
Kind relationships
People were treated with kindness and respect. Inspectors saw positive relationships between people and staff, with support for dignity and independence.
“People were well treated and supported by a regular staff team that understood their needs well.” from the report
Personalised care
Care plans included people's preferences, history and hobbies. People had choice about their routines, activities and how they spent their time.
“Care plans were written in a person centred manner and included people's likes, dislikes, work and personal history.” from the report
Good food and healthcare support
People's food preferences and dietary needs were recorded and supported. Staff arranged healthcare referrals and used information to help respond to changes in people's health.
“People were well supported with food and drink.” from the report
Risks were not always identified
seriousSome care plans did not contain important guidance, including guidance about diabetes deterioration and a newly fitted catheter. Exposed hot water pipes and poorly fitting radiator covers also created a scalding risk.
“However, we found some risks to people that had not been identified.” from the report
Medicine recording problems
seriousRecords for pain relief patches were inconsistent, creating a risk that old patches might not be removed. One medicine risk assessment was incomplete and one as-needed medicine was given without recording the reason.
“We found inconsistencies in how staff were recording the administration of pain relief via a patch.” from the report
Infection control shortfalls
needs fixingMoving and handling slings belonging to different people were stored together, creating a risk of cross-contamination. Some cleaning records also had gaps.
“This meant there was a risk of cross contamination.” from the report
Management systems did not fix known problems
seriousAudits had not identified several risks, including medicine storage temperatures and an incorrectly set pressure-relieving mattress. The provider had not made enough improvement after the previous enforcement action.
“Not enough improvement had been made at this inspection and the provider remained in breach of regulation 17(1).” from the report
- 01What changes have been made to ensure diabetes, catheter and scalding risks are recorded and reviewed in each person's care plan?
- 02How are pain relief patches and as-needed medicines now recorded and checked?
- 03How do you check that each person's moving and handling equipment is labelled, stored separately and cleaned safely?
- 04What action has been taken after the finding about medicine room temperatures and the incorrectly set mattress?
- 05How will you show that the Regulation 17 breach and the earlier warning notice have been fully addressed?
This was an unannounced follow-up inspection prompted by emergency-care concerns and earlier required improvements; it assessed all five key questions, with Effective improving to Good while Safe and Well-led remained Requires Improvement. This explanation was written from the published report of 18 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2023
Linden Manor was rated Requires Improvement; inspectors found risks with medicines, staffing and care records, and issued warning notices.
This was an unannounced focused inspection. Inspectors visited on 26, 30 and 31 January and 2 February 2023. They looked only at Safe and Well-led because concerns had been raised about staffing, safeguarding and environmental safety.
Inspectors found that risks were not always identified or managed. One person had prolonged periods of high blood glucose without staff seeking medical advice. Medicines were not always given as prescribed, records were incomplete, and some environmental and infection control risks had not been dealt with.
Management checks did not identify these problems. Care plans and risk assessments were sometimes out of date or incomplete, and records did not always show that people received the care set out in their plans. Staff knew people well and people and relatives said managers were accessible.
The overall rating remains Requires Improvement, as it was at the previous inspection in June 2021. The report says the home has been rated Requires Improvement at the last two inspections.
Safeguarding knowledge
Staff knew people well and understood how to recognise and report abuse. Safeguarding training was up to date.
“Staff knew people well and understood how to protect them from abuse.” from the report
People felt safe
People and relatives told inspectors they felt safe and believed people were well cared for.
“One person said, "I feel safe, the staff know what they are doing.” from the report
Accessible management
People and relatives said the registered manager was visible, listened to them and communicated well.
“People and relatives said communication from the registered manager was good, they were accessible and listened to people.” from the report
Staff support
Staff said they felt supported and confident about raising concerns with managers.
“Staff felt supported within their roles and felt confident to discuss any concerns they may have with the management team.” from the report
Diabetes risks
seriousStaff were giving insulin as a delegated healthcare task, but risks linked to diabetes were not properly recorded or managed. One person had prolonged high blood glucose without medical advice being sought.
“Staff did not seek medical advice when 1 person experienced prolonged periods of high blood glucose which placed them at increased risk of serious medical conditions.” from the report
Medicines
seriousSome controlled medicines were not given as prescribed and stock checks were ineffective. Instructions for medicines given when needed were not always available.
“We found people had not always received their controlled drugs as prescribed and stock management of controlled drugs was ineffective.” from the report
Care records
seriousCare plans and risk assessments did not always reflect current needs. Records did not always show that people received required repositioning and other support.
“People's care plans and risk assessments contained incomplete information about people's risks in relation to pressure ulcers and nutrition and hydration needs.” from the report
Staffing levels
needs fixingPeople and relatives reported that the home was sometimes short-staffed, particularly at weekends. On some nights only two staff worked instead of the planned three.
“On occasion, due to sickness, the home had been staffed with only two staff overnight, rather than the planned three staff.” from the report
Environmental and infection risks
seriousA tap had been recorded as producing water above the safe temperature, with no action taken. Hoist slings were shared in a way that created a risk of cross-contamination.
“There was unhygienic and unsafe use of hoist slings as people who required the use of a hoist to move were not allocated their own hoist sling to use.” from the report
- 01What has changed in how medicines, including controlled medicines and as-required medicines, are checked and recorded?
- 02How are people with diabetes now monitored, and who is responsible for responding when blood glucose levels are outside the safe range?
- 03What staffing levels are guaranteed on weekdays, weekends and overnight, including when staff are absent?
- 04How are care plans and repositioning records checked to make sure people receive the support they need?
- 05What action has been taken on water temperatures, fire safety actions and the use of hoist slings?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous inspection. This explanation was written from the published report of 1 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Linden Manor
8 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2021Requires improvementSafe: Requires improvementWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not rated
- February 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 21 August 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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