CQC report explained · a residential care home
What the CQC found at The Lindens Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk management, medicines, infection control, recruitment and staffing had improved. However, safeguarding incidents and injuries were not always reported to the right authorities, and staff deployment could be improved.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Well-led?
- Requires improvement
- Management had improved communication, auditing and involvement of relatives. However, required notifications were still missed and people's care records were not consistently maintained.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found better care and management, but safeguarding notifications and care records were still not reliable.
This was an unannounced focused inspection over three days in November 2022. Inspectors spoke with people, relatives, staff and a visiting professional. They observed care, checked the home and reviewed care, medicine, staff and management records.
The home had improved since its previous inspection, when it was rated Inadequate. People and relatives generally felt the care was safe, kind and more consistent. Medicines, risk management, staffing, training and visiting arrangements had improved.
However, safeguarding incidents and injuries had not always been reported to the local authority or the CQC. Care records were not always up to date or accurate, including some falls, turning and fluid records. These failures meant the home remained in breach of two regulations.
The overall rating changed from Inadequate to Requires Improvement. The home is no longer in Special Measures, but the CQC will monitor its action plan and progress.
Better risk management
Risks such as falls, choking, medicines, moving and handling and fire had been assessed. Staff understood the risks and the actions needed to reduce harm.
“People who were at risk of harm due to their medical condition, cognitive functioning, choking, use of bed rails, specific medicines such as anti- coagulants and flammable creams had risk assessments in place to help staff reduce harm to them.” from the report
Medicines
Medicine systems had been reorganised. Records showed medicines were given as prescribed, with audits and trained staff in place.
“The medicine administration records showed medicines were given as prescribed, with medicine audits taking place to ensure safe medicine practices were promoted.” from the report
Consistent staff team
Staffing levels had increased and the home was using an experienced team without agency staff. Relatives valued seeing familiar staff who knew people well.
“The service had an established experienced staff team with no agency staff in use.” from the report
More open involvement
Visiting arrangements had improved and relatives were encouraged to take part in care planning and meetings. Inspectors saw warm and welcoming interactions.
“Relatives were actively encouraged to be involved in their family members care with open visiting promoted.” from the report
Safeguarding reports were missed
seriousSome incidents involving violence between people and a serious pressure wound were not reported promptly to the local authority or the CQC. The provider was asked to improve safeguarding reporting.
“The previous registered manager had failed to report safeguarding concerns to the local authority and to us.” from the report
Required notifications were not made
seriousThe home had not notified the CQC about some incidents, including injuries after falls. This remained a breach of Regulation 18.
“This was a continued breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009, as the provider had not notified us of all events it was required to.” from the report
Care records were incomplete
seriousSome records did not clearly describe people's needs or the support they required. Falls assessments, daily records, turning records and fluid charts were not always complete or updated.
“Records were not routinely kept up to date and accurately completed.” from the report
Staff deployment
minorAlthough inspectors found enough staff overall and no harm occurred, they saw 16 people in one lounge on three occasions without staff present. The manager was asked to consider how staff were deployed.
“We observed 16 people in one lounge on three occasions without any staff presence.” from the report
- 01How do you now make sure every safeguarding concern and injury is reported promptly to the local authority and the CQC?
- 02How are care plans, falls assessments, turning records and fluid charts checked for accuracy and updated after a person's needs change?
- 03How do you make sure staff are present in communal lounges and deployed safely at all times?
- 04What progress has been made in moving care plans to the electronic records system?
- 05How are relatives involved in care planning and kept informed about incidents, health changes and improvements?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 December 2022 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 2022
Rated Inadequate and placed in special measures; inspectors found serious risks in care, safeguarding, medicines, consent and management.
This was an unannounced focused inspection on 25 January, 2 February and 3 February 2022. Inspectors looked at concerns about visiting and widened the inspection to Safe and Well-led. They spoke with people, relatives, staff and visiting professionals, observed care and reviewed care, medicine, staff and management records.
The home was rated Inadequate for Safe and Well-led. Inspectors found risks were not always identified or reduced. Medicines were not always given as prescribed, the safeguarding arrangements were not suitable, recruitment checks were incomplete and some infection control practices did not follow government guidance.
Inspectors also found weak management systems. Audits did not identify problems, records were incomplete, staff training and supervision were not properly overseen, and the home did not follow the Mental Capacity Act when making some decisions about care, restrictions and visits. The overall rating fell from Good at the previous inspection in March 2019 to Inadequate.
Controlled medicines
Records for controlled medicines had improved since the previous inspection and accurately reflected the medicines in use.
“At this inspection we found controlled medicines were appropriately managed and records accurately reflected the controlled medicines in use.” from the report
Staffing continuity
Inspectors reported that the home had an established staff team and staff said staffing levels were sufficient. The home said it did not use agency staff.
“The service had an established staff team who demonstrated a good understanding of people's needs.” from the report
Health professional links
Visiting health and social care professionals gave positive feedback about how the home worked with them to support people's health.
“The service worked with relevant health professionals. We spoke with three health and social care professional during our visit who gave positive feedback about how the service worked pro-actively with them to get good health outcomes for people who used the service.” from the report
Unmanaged risks
seriousSome risks were identified but not properly managed. Inspectors found concerns involving falls, choking, distress, pressure damage, bedrails, fire safety and a hot uncovered radiator.
“Risks were not always identified and where they were, they were not mitigated.” from the report
Unsafe medicines practice
seriousInstructions for some medicines given when needed were unclear. Creams were not consistently recorded or applied, and a medicine trolley had been left unsecured because its lock was broken.
“People had unrestricted access to medicines which were not prescribed to them.” from the report
Safeguarding arrangements
seriousThe safeguarding policy did not match local safeguarding procedures, and people were not given clear information about what to do if they felt unsafe.
“People were not safeguarded from the risk of abuse.” from the report
Recruitment and staff support
seriousSeveral staff files lacked suitable references or clear evidence of checks. Staff supervision was not happening as often as the home's policy required, and specialist training was not kept up to date.
“Recruitment procedures were not operated effectively to ensure fit and proper staff were employed.” from the report
Consent and restrictions
seriousThe home did not complete the required capacity and best-interest records for some decisions. Inspectors found a lap belt was used without the required records, and visiting restrictions were not properly based on people's preferences or consent.
“People were not consented with on their care and the service did not work to the principles of the Mental Capacity Act 2005.” from the report
Weak oversight and records
seriousAudits failed to find problems that inspectors identified. Care records, fluid charts, turning charts, medicine records, incident records and fire checks were incomplete or inaccurate.
“Quality assurance and monitoring systems were not effective as audits were not able to pick up the concerns we had found.” from the report
- 01What action has been taken to reduce the risks from falls, choking, distress, pressure damage, bedrails and fire safety?
- 02How are medicines given when needed now, and how do you check that creams and other medicines are administered as prescribed?
- 03How do you ensure every new staff member has the required references, DBS evidence, induction, training and supervision?
- 04How are mental capacity assessments and best-interest decisions recorded for restrictions, care and visiting arrangements?
- 05Has the CQC re-inspected since this report, and what progress has been made against the action plan and warning notices?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 2 April 2022 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 The Lindens Care Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- March 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Registered with the Care Quality Commission on 14 August 2014.
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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