Linson Court

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. This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The provider was in breach of the legal regulations in relation to safe and effective staffing and safe care and treatment.

This service scored 62 (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.

Accidents and incidents were reported by staff and action was taken to mitigate the risk of events happening again. Some improvements were required to how complaints and concerns were reviewed to ensure any themes and trends were fully assessed, to prevent events happening again. There were daily handovers and flash meetings which meant staff were kept up to date about any events. People had access to professionals, family and friends outside of the service who they could raise concerns with about safety.

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.

Continuity of care was maintained by ensuring staff had access to clear records. People’s needs were assessed before they started using the service and there were good links with health and social care professionals.

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.

There were clear processes in place to manage safeguarding events and the registered manager worked collaboratively with the local authority to support people safely. There was a detailed safeguarding log which highlighted good communication with people and the local authority. Staff had received safeguarding training and understood how to recognise and report poor care and abuse. Safeguarding was routinely an agenda item in team and clinical meetings. Where people were subject to Deprivation of Liberty safeguards (DoLS) the service had made applications to the local authority and there was clear monitoring in place. DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.

People and relatives told us they felt safe. Comments included, “Yes [relative] is safe, and it is good for us that they are here, and I feel more at ease now.”

The provider did not always work well with people to understand and manage risks.

Risks to people’s health, safety and wellbeing were assessed and regularly reviewed. Key risks such as fire, falls, and nutrition and hydration were assessed and monitored.

Where risks were highlighted in relation to people’s skin integrity, we found inconsistencies in people’s care records and safe practices were not always in place. Where people had been assessed to need pressure relieving mattresses the provider’s guidance highlighted, they should be set according to their current weight. We reviewed 6 people’s specialist mattresses and found they were not at the correct setting. This had not been identified in daily checks recorded by staff. Where people required regular repositioning, this was not carried out consistently. Records showed significantly longer intervals between repositioning than those stated in their care plans. We observed care was not always delivered in line with people’s care plans, which exposed them to the risk of harm and their skin and health deteriorating.

Where people required support with moving and handling, there were clear risk assessments in place, and we observed staff following plans of care and using equipment safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was tidy, well maintained and safe and there were systems in place to ensure the required health and safety checks were completed. There was a dedicated maintenance worker on site which meant any shortfalls could be addressed promptly. People had access to safe equipment where needed. There were a range of comfortable communal areas and a safe garden area. People’s bedrooms were personalised and spacious with en-suite facilities.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development. They worked together to provide safe care that met people’s individual needs, but there were challenges due to the numbers and deployment of staff.

Safe staffing levels were not always in place, and this was confirmed by staff. A dependency tool was used to assess how many staff were on duty and this was regularly reviewed. The provider told us they worked with commissioning teams to ensure this reflected adequate staffing levels. However, our observations over 2 days indicated staff were often rushed and this meant people had to wait for care and support. For example, people told us they had to wait for their breakfast serving and we saw people supporting each other by offering snacks and helping adjust other people’s clothing as there were no staff available. Our observations about the staffing levels were confirmed by a high number of people, relatives and staff who also highlighted concerns about staffing at busy times. There were a high proportion of people who were cared for in bed and frequently required the support of 2 staff to meet their care needs. People in communal areas did not have access to call bells.

We raised our concerns about staffing levels on the first day and the provider was responsive and increased staffing levels on the first floor. However, we continued to observe and hear concerns about there not being enough staff at busy times.

People and relatives told us they did not think there were enough staff. Comments included, “There is not enough staff, and you have to wait for help to come.”

Staff also raised concerns about the number of staff and confirmed this meant they could be rushed, and people had to wait for care and support. Comments included, “I think it is based on numbers and not needs.”

Recruitment was managed safely. Staff had good induction, support and training to be able to carry out their role. There was a dedicated training room and staff told us the training they received was to a high standard.

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.

Processes were in place to ensure people were protected from the risk of infection. The service was clean and tidy, and staff followed good practices to keep people safe, and their standards were regularly checked. The registered manager had a system to check any infections which were diagnosed and was proactive in ensuring people were offered timely vaccinations if they wished. People and relatives complimented the cleanliness of the service.

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

The service had a dedicated clinic room, and overall systems were in place to manage people’s medicines safely. However, we found some areas for improvement and observed shortfalls in practice. We saw a medication pot containing multiple tablets had been left by a person’s bed, where the person had not been assessed to be able to self-administer safely. In addition, the staff member had signed for time specific medicines at a certain time but confirmed to the inspector they had not observed the person taking them. This meant the person, and other people who had access to the tablets, were exposed to the risk of harm.

Protocols for ‘as and when required’ medicines were in place, but they were not always well completed and there were gaps in recording why the medicines were administered and the result. This area for improvement had been identified in the provider’s audits in August and September 2025 and had not been rectified.

Medicines recommended by the manufacturer to be taken early morning were not always given prior to the person having breakfast. The registered manager said they would address this without delay.

People and relatives did not raise any concerns about the support they received with their medication.