Linden Lodge Nursing Home

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good.This meant people were safe and usually protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Relatives told us they were always informed about safety incidents and felt staff listened carefully to any concerns or suggestions. Staff described a collaborative, solution‑focused approach to learning from events to improve outcomes for people. One staff member explained when an incident occurred, an accident form was completed with clear actions to reduce the risk of recurrence. They told us, “We discuss what could be implemented, and once agreed, it is added to the handover so everyone is aware. If falls continue, we review the situation again and explore further options.”

Senior staff actively monitored day‑to‑day practice and provided immediate feedback to maintain safe care standards. Where practice required improvement, senior staff used a counselling form to document discussions, create a clear audit trail and support reflective learning or, where appropriate, formal action.

The registered managers regularly reviewed all incidents to identify patterns, to ensure learning was embedded and confirm all required actions to reduce risks had been completed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People experienced safe and well‑coordinated transfers because they were supported by family members or staff who knew them well. Staff followed clear processes to ensure essential information accompanied people during any hospital admission. One staff member explained they sent the person’s RESPECT form, an emergency red bag and a printed hospital pack so clinical teams had immediate access to key details.

For planned health appointments, staff worked in partnership with families wherever possible. A staff member told us, “If families are willing and able, we ask if they can go with the person. If not, we arrange ambulance transport and ensure a member of staff is available to support them.” This approach ensured people were accompanied by someone familiar, with their needs understood throughout the transition.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People spoke positively about how their rights and safety were upheld. One person told us, “I feel safe, it seems to be secure here,” while another person said their needs were consistently met. They added, “I feel safe because all staff are very nice and caring.”

Staff demonstrated a strong understanding of safeguarding and their duty to protect people. They were clear about how to report concerns and were confident the management team would act promptly. One staff member said, “It is my role to speak up for them if they can’t do it themselves.” Another described their commitment to escalating concerns to other organisations, should this be required, explaining they would whistle blow if required to ensure people were protected.

There were well established processes for identifying, reporting and managing safeguarding concerns. The service worked effectively with external safeguarding agencies, ensuring people received timely support and to help to ensure people received the help and care they needed.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The provider had identified where a deprivation of liberty needed to be authorised and had submitted the required applications to the supervisory body.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives told us they felt confident about how risks were managed. One relative described how staff took time to involve their family member in decisions and helped them understand the reasons behind safety measures. They said, “Staff talked about safety, they were supportive and coaxed [person’s name] along really well. They took time to explain why a particular type of chair would be best for their safety and comfort.”

People’s individual risks were clearly identified, and robust plans were in place to manage, monitor, and reduce these risks. Assessments considered both people’s emotional needs, such as triggers which may lead to a person becoming anxious, and physical health risks, including skin integrity concerns on admission and risks associated with falls, poor nutritional intake and catheter use. Staff had clear guidance on how to respond, what early warning signs to look for, and when to escalate concerns.

Staff showed a good understanding of the risks people faced and were able to explain how they supported individuals to manage these risks while still promoting choice and independence. For example, staff offered gentle reminders to use mobility equipment, enabling people to move safely around the home without restricting their freedom.

Staff consistently worked in a way which balanced risks with what mattered to people, helping them stay safe without limiting their autonomy. We saw staff supported people to spend time in the garden, walking alongside them and checking regularly the pace was comfortable. This approach ensured people remained safe while also respecting their wishes to be outdoors and maintain their preferred routines.

The provider did not always detect and control potential risks in the care environment, but they made sure most equipment, facilities and technology supported the delivery of safe care.

On the first day of the inspection, we identified some improvements were needed to ensure the premises were managed safely and to further reduce environmental risks. These included replacing window restrictors with tamper‑proof versions, removing items stored in the roof eaves, and fitting a more secure lock to the eave’s door. By the second day of the inspection, these issues had either been fully resolved or clear, timely plans had been put in place, with interim safety measures implemented to keep people safe.

However, the home was bright and welcoming, and people told us they liked their rooms and valued the sense of security at the home. Regular checks were undertaken on key aspects of the safety of the building and incoming services, such as gas, water and electrical safety and where any actions in relation to fire management had been identified these were promptly actioned.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were generally positive about staffing levels and the support available to them. One person told us, “There is always someone there to listen if you have a problem.” Another said, “When you press the buzzer, they do not take long to come to you.” A small number of people and relatives told us there were occasional waits during busier periods, but this did not reflect the majority of feedback we received.

During the inspection, staff were visible, attentive and available to respond when people requested assistance. Staff were not rushed and had time to engage meaningfully with people as they carried out their roles, which contributed to a calm and supportive environment.

Staff told us they felt staffing levels were safe and appropriate, while acknowledging people’s changing needs could sometimes create additional pressures. One staff member said, “I think there are enough care staff to support the residents we have.”

People and relatives were complimentary about the way staff used their skills to provide care. One relative said, “They absolutely know what they are doing.” Staff were supported to deliver safe and effective care through ongoing training and opportunities to develop their skills. Staff were confident additional training would be provided to meet people’s needs, when required. The management team were in the process of arranging additional training to ensure all staff had opportunities to undertake specific training, to equip staff with the skills required to support people with learning disabilities.

Managers had processes in place to regularly review staffing levels in line with people’s needs and to monitor response times to call bells. Staff gave examples of how staffing had been increased proactively when people’s needs changed, to maintain safe staffing levels.

Systems were in place to ensure staff were recruited safely. This included checking their eligibility to work in the UK, obtaining references and Disclosure and Barring Service (DBS) checks. The DBS checks help employers make safer recruitment decisions and prevents unsuitable people from working with vulnerable people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People told us the home was kept clean, tidy and well maintained. One person said, “It’s always clean and tidy in [the communal areas] and in our rooms.” Relatives shared similar positive feedback about the standard of cleanliness throughout the home.

Staff confirmed they had access to the PPE, [personal protective equipment], and cleaning equipment needed to maintain good infection prevention and control practices. Housekeeping staff followed structured cleaning schedules to ensure all areas of the home were cleaned regularly and to a high standard.

There were robust processes in place to ensure people, visitors and staff were promptly informed when infections were present in the home. A staff member told us in the event of any outbreak, “There are signs on the [front] door and all down the corridors and we also discuss it at handovers, and tell the relatives.”

Housekeeping staff were immediately notified so they could adapt cleaning routines to break the chain of infection and minimise risks. Clear information was displayed throughout the home to guide staff on best‑practice infection prevention measures. These arrangements supported a proactive, well‑coordinated and effective approach to keeping people safe by reducing the likelihood of infections.

The provider did not always make sure that medicines and treatments met people’s needs, and preferences.

Most systems for safe medicines management were working effectively. People told us they received their medicines reliably, with 1 person saying, “They give me medication on time and don’t forget.” Most relatives shared this view. However, 1 relative reported their family member had previously waited for pain relief, and another person told us their medicines were occasionally given, “A little late,” although never missed.

We found some topical medicines, including creams, eye drops and ibuprofen gels, were not consistently dated in line with best practice guidance. Dating these items is important to show how long a medication is expected to stay effective and contaminant-free. Registered managers gave assurance this would be addressed promptly.

However, staff were only permitted to administer medicines once they had completed appropriate training and had their competency assessed. Safe arrangements were in place for managing ‘as required’ (PRN) medicines, and people’s medicines were regularly reviewed to ensure they continued to receive the therapeutic benefits intended. A health and social care professional told us staff alerted them when medicines were no longer needed, which helped to reduce unnecessary prescribing and minimise wastage.

Staff had developed detailed care plans for people with higher‑risk medicines, such as those receiving anticoagulation therapy. People’s medicines were stored securely and disposed of safely, in line with best practice.