Lindum Court requires improvement overall due to breaches in good governance (Regulation 17), including absent incident recording systems and inconsistent safeguarding reporting. Strengths include safe medicines management, effective infection control, good staffing, and a positive person-centred culture.
Concerns (4)
criticalSafeguarding: “Safeguarding concerns had not always been reported appropriately. Although the registered manager had a system in place to support safeguarding concerns, further work was needed.”
criticalIncident learning: “There was limited evidence of learning from accidents or incidents and what, if any action was taken when things went wrong.”
criticalGovernance: “There were limited systems and processes in place to ensure regular audits with action plans were taking place to improve the quality and safety within the service.”
moderateRecord keeping: “There was no recording of incidents within the service or regular audits of care records.”
Strengths
· Risks to people's safety were assessed appropriately and person-centred risk plans were in place.
· Medicines were managed, stored and disposed of safely with annual competency checks for staff.
· Infection prevention and control measures were effective and aligned with national guidance.
· Sufficient staffing levels with safe recruitment and selection processes.
· Staff training was up to date including specialist areas such as diabetes, pressure ulcers and sepsis.
Lindum Court achieved an overall Good rating following significant improvements since a previous inspection that identified breaches of Regulations 12 and 17. The Well-led domain was rated Requires Improvement as sustained, consistent improvement over time had not yet been demonstrated, though governance systems had been substantially strengthened.
Concerns (2)
moderateGovernance: “we could not rate the service higher than requires improvement for 'well-led' because to do so requires consistent and sustained improvement over time.”
moderateMedication management: “we observed a member of staff administering people's medicines at lunchtime...Following administration it was noted an error had occurred.”
Strengths
· All shortfalls from the previous inspection had been addressed, including cleanliness, infection control, and environmental hazards.
· People told us they felt safe living at the service and relatives confirmed their family members were safe.
· Staff were attentive and kind, supporting people in a gentle enabling way which promoted independence.
· Robust safeguarding procedures in place; staff knew how to recognise and report abuse.
· Sufficient staffing levels maintained, including when providing community care.
Lindum Court received an overall rating of Requires Improvement, with Well-led rated Inadequate following breaches of Regulations 12 and 17, driven by persistent environmental hazards, poor infection control and ineffective governance that had not been addressed since the previous inspection. Strengths included caring staff who treated residents with dignity, adequate staffing levels, robust recruitment and good nutritional care.
Concerns (8)
criticalInfection control: “We found all areas of the service to be dusty which showed the cleaning schedules were not effective. We saw there were shortfalls throughout the service relating to infection control.”
criticalGovernance: “The registered provider had failed to take appropriate action following our last inspection. This demonstrates inadequate management and a failure by registered provider to take action about known risks.”
criticalSafeguarding: “Gloves, plastic bags prescribed creams and razors were not securely stored to help to prevent the risk of harm to people living with dementia.”
moderateRecord keeping: “Risk assessments for some people lacked detail and direction and behavioural support plans were not fully detailed or prescriptive.”
moderateCare planning: “We found one person needed their care file updating as they were now unable to get out of bed. This was discussed with the registered manager and the care records were reviewed immediately.”
moderateLeadership: “The registered manager managed two locations for the registered provider. This may have contributed to this location being inadequately managed.”
moderateMedication management: “The storage of prescribed creams for people unsecured in their bedrooms posed a risk of harm to people especially to those living with dementia.”
minorConsent / capacity: “Capacity assessments, and best interest decisions were recorded on a document that was not headed with the registered providers name... this could be misleading.”
Strengths
· Staff treated people with kindness and respect, offering gentle and enabling support to promote independence and choice.
· Staff recruitment procedures were robust, including references, interviews and DBS checks.
· Staffing levels were adequate; staff covered each other's absences to maintain continuity of care.
· Staff received training, supervision and appraisals to maintain and develop their skills.
· People's nutritional needs were assessed, monitored and catered for, with input from relevant health professionals.
Quality-Statement breakdown (16)
safe: Safe care and treatment (Regulation 12) — environment, infection control and hazard managementRequires improvement
Lindum Court required improvement in three of five key areas, with principal concerns around unlocked unsafe storage areas, staff appraisals not completed since 2012, and insufficiently robust internal audit processes. Caring and responsive domains were rated Good, supported by positive staff-resident interactions, person-centred care records, and effective complaints and activities provision.
Concerns (5)
moderateGovernance: “Audits within the service were not as robust as they could have been... the frequency these audits took place was not clear.”
moderateSupervision / appraisal: “We noted that staff appraisals had not been completed since 2012.”
moderateOther: “Some areas within the service were being used as storage space but were still accessible to people who used the service presenting a risk to their safety.”
minorLeadership: “Sometimes staff issues are openly discussed throughout the service by the manager and staff... The manager gets grumpy if you're off sick.”
minorPerson-centred care: “The service did not have a planned activities programme and planned activities were not displayed so that people who used the service knew what was happening.”
Strengths
· Staff had good knowledge of safeguarding and had completed SOVA training; people felt safe living at the service.
· Medicines were administered safely, recorded correctly, stored in locked cupboards, and staff had received appropriate training.
· Sufficient staffing levels were maintained and safe recruitment practices including DBS checks were followed.
· Positive, respectful interactions between staff and people using the service; dignity and privacy were consistently upheld.
· Care records were person-centred, containing life histories, risk assessments and end of life care plans.
Quality-Statement breakdown (18)
safe: SafeguardingGood
safe: Medicines managementGood
safe: Staffing levels and recruitmentGood
safe: Environmental safetyRequires improvement
effective: Staff training and inductionGood
effective: Staff appraisalsRequires improvement
effective: Consent and Mental Capacity ActGood
effective: Nutrition and hydrationGood
caring: Kindness, dignity and respectGood
caring: Involvement of people in their careGood
responsive: Care planning and assessmentRequires improvement
responsive: Activities and social engagementGood
responsive: Complaints handlingGood
well-led: Good governance (Regulation 17) — quality monitoring and auditingInadequate
well-led: Registered activity compliance and regulatory understandingInadequate
well-led: Staff engagement and organisational cultureGood
effective: Healthcare professional involvement
Good
caring: Dignity and respectGood
caring: Involvement in careGood
caring: End of life care planningGood
responsive: Care planning and person-centred careGood
responsive: ActivitiesGood
responsive: Complaints handlingGood
well-led: Governance and auditRequires improvement
well-led: Leadership and cultureRequires improvement