The Limes

The Limes is a care home which provides accommodation and personal care for those who may have dementia or a physical disability. The service can support 97 people in one adapted building, with a separate unit for people living with dementia. At the time of the inspection 75 people were using the service.

People’s experience of using this service and what we found

People were not always receiving a service that provided them with safe, effective, well led care. We received mixed feedback from people about their experiences at the service. Some people’s experiences were positive, however other people did not experience this same level of care or support.

Risks to the health and safety of people were not consistently monitored and mitigated. This included risk associated with catheter care and individual health conditions. Staff had not always had sight of people's care plans or risk assessments. Medicines were not managed safely.

There was insufficient staff to meet people's needs. People and staff reported delays in providing care due to staff shortages. The tool used by the provider to calculate staffing levels did not always contain accurate information about people’s support needs.

Staff moral was low and staff did not always feel supported or listened to. Staff did not always benefit from training and constructive supervision to support them in their role.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The mealtime experience for people was poor and did not always follow best practice. People and staff gave negative feedback about the meals provided.

The provider lacked the appropriate systems and processes to drive forward improvements in a timely manner. The provider's own systems of oversight had not identified the concerns we found during the inspection.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 18 October 2017).

Why we inspected

The inspection was prompted in part due to concerns received about medicines, staffing and management oversight. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, staffing and management oversight at this inspection. We have made a recommendation about the mealtime experience at the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

• Systems were in place to isolate people with COVID-19 to minimise transmission. The service had good supplies of personal protective equipment (PPE) that were readily available in stations throughout the service. Clinical waste bins were positioned so that staff could access them when required.

• Staff had received update training on how to keep people safe during the COVID-19 pandemic and were regularly tested in line with the government's current testing programme. Staff maintained social distancing where possible and the environment promoted people to remain socially distanced.

• The home had a team of housekeeping staff that had been trained on infection control. There was an enhanced cleaning schedule in place that also ensured door handles, key pads, hand rails and high touch areas were consistently cleaned. We observed that the home was very clean and well kept.

• At the time of our visit the service was closed for non-essential visitor's. A visitor's protocol was in place to ensure anyone entering the service was temperature tested, completed hand disinfection and provided with information to remain safe during their visit.

At the last inspection the service was rated as Good overall. At this inspection we found that the service remained Good.

There were sufficient numbers of staff employed to make sure people received the support they needed, and those staff had been safely recruited.

Staff received appropriate training that gave them the knowledge and skills they required to carry out their roles. This included training on the administration of medicines and on how to protect people from the risk of harm.

People were supported to have choice and control over their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff were kind and caring, and they respected people’s privacy and dignity.

Care planning described the person and the level of support they required. Care plans were reviewed regularly to ensure they remained an accurate record of the person and their day to day needs.

People and their relatives told us they were aware of how to express concerns or make complaints and we saw any complaints made had been thoroughly investigated and responded to.

The registered manager carried out audits to ensure people were receiving the care and support they required. People were also given the opportunity to share their views about the service provided.

The feedback we received and our observations on the day of the inspection demonstrated that the home was well managed.

Further information is in the detailed findings below

The home is registered to provide accommodation and care for up to 97 older people, including people who are living with dementia. There were 96 people living at the home on the day of this inspection, including seven people who were having respite care. The home is situated in Driffield, in the East Riding of Yorkshire. There is an area of the home where people who are living with dementia are accommodated and another area for older people; these are staffed separately. All accommodation is on the ground floor and there are enclosed courtyards where people can access outdoor areas safely. People have single bedrooms with en-suite facilities, and there are also communal bathing and showering facilities.

The registered provider is required to have a registered manager in post and on the day of the inspection there was a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we saw that staff had completed training on non-abusive psychological and physical intervention (NAPPI). This training aims to equip staff with the skills to safely manage people who display behaviours that might challenge the service. We saw that this training had been incorporated into staff induction training. Staff had received other training to help them to carry out their roles effectively, and they received support from a senior manager in supervision and appraisal meetings.

The service was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We saw that people’s capacity to make decisions had been assessed and when people lacked the capacity to make decisions for themselves, best interest decisions had been made on their behalf and recorded.

People’s nutritional needs were assessed and their special diets were catered for. People received support from health care professionals when required and we found that staff followed any advice and guidance they were given.

The area of the home where people living with dementia were accommodated had been refurbished. This provided high quality accommodation that included space for people to move around freely, signage to help people find their way around the premises and various ways of providing orientation for people. The dining room was in the style of a cafeteria which provided clear prompts for people to indicate this was where food and drink was served.

We carried out this inspection to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity and we observed caring and compassionate care by the staff. People told us they felt safe. People had their own care file and these contained an assessment of needs for example; mobility, eating and drinking, mental health, skin care, social activity, monitoring charts and contact with other professionals. This contained information about the way each person should be supported and cared for. Additional information included risk assessments to ensure people remained safe from harm.

We looked at safeguarding referral records that were recorded to ensure people who used the service were kept safe from harm. We found the records accurate and complete and when required, a notification was sent to us at the Care Quality Commission (CQC). This meant that people were protected from the risk of harm.

A visiting relative told us, 'My relative was admitted here urgently and then went home after a while but she wanted to come back here. I have never overheard or seen anything negative from the staff, they are all so friendly.'

We looked at medicine administration records (MAR) documentation and found these to be accurate, precise and transcribed in a clear and consistent manner. People's MAR documentation also included a photo of the person to reduce the risk of inaccuracies.

Is the service effective?

We observed a number of care and support activities that staff undertook. We saw that staff appeared calm, very supportive and compassionate with people's needs. Staff were able to describe people's needs and how these should be best met. We saw that daily notes detailed what care the person received.

We spoke with people who used the service. Comments included, 'Staff know what they are doing and they ask you how you are and if you are happy. I do feel safe here', 'It's nice here. The staff are very kind and I have a nice room' and 'I decide whether I want to get up, it's up to me.'

Is the service caring?

Staff we spoke with were clear and precise about their role. One staff member we spoke with told us, 'We review peoples care plans with them regularly and discuss their 'day to day' lives with them. We have a six weekly review too which goes into much more detail.' Records we looked at corroborated this.

We spoke with a visiting health care professional and they told us, 'I visit quite often and the service always appears well organised and they know we are coming. Paperwork is always well prepared and they are very on the ball. Staff are very caring and they are accommodating and have helped with urgent admissions in the past when needed.'

Is the service responsive?

We observed a game of cards being played by five people and they appeared to have enjoyed the session. We observed some people who used the service choosing their favourite book from the mobile library that attended the service. We also observed the lunchtime session which was well organised and staff were clear about their roles in supporting people that needed it.

We spoke with visiting relatives of people that used the service and they told us, 'The care is very good here and the owners are often available to answer any questions we have', 'My relative always looks well and staff deal with accidents promptly and respectfully' and 'Staff handle people's good and bad moods very well, without being patronising.'

People knew how to make a complaint if they were unhappy. We looked at how these complaints had been dealt with, and found that the response had been open, thorough, and timely. People were therefore assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service had an effective quality assurance system in place and records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We saw records that showed the service had completed a 'residents and relatives' survey in July 2013 and another survey had been completed in January 2014.

We saw responses from people who used the service, their relatives and other professionals. We saw that survey responses were received from 29 people who used the service, 14 relatives and nine professionals. An analysis of results was completed and a 'survey action plan' was completed to ensure any concerns raised was captured and acted on.

We saw records of regular meetings had taken place for different staff groups for example; care day staff, care night staff, seniors, domestic and laundry staff. Records we looked at confirmed meetings were well attended and discussed topics for example; personal care, equality and diversity, care plans, keyworker notes, teamwork, and cleanliness.

We found people were being looked after by friendly, supportive staff within a warm and homely environment. Care was risk assessed and records were up to date. Relatives told us that communication between the staff and people was 'Brilliant'.

People who used the service were supported to take part in a range of activities both within the service and out in the community. We spoke with people who were taking part in activities and they told us 'There are plenty of things for us to do here', 'We are spoilt for choice' and 'The staff always have time to chat with you'.

Infection control systems within the service were looked at. These were monitored regularly by the provider. People told us 'The home is immaculate, our bedrooms are cleaned daily and the staff keep everything spotless.'

We saw the service had an effective recruitment policy and procedure, which ensured staff working in the home had the right skills and qualifications to meet people's needs.

The provider had an effective quality assurance system in place and people's views and opinions of the service were listened to and acted on where necessary. One relative said 'The home is like a five star hotel, I cannot fault it'.

People said 'The care staff are lovely, they look after us very well and the food is nice with plenty of choices.' One relative told us 'The care here is very good and people are happy and safe.'

Sufficient staff were on duty to meet the needs of people who used the service. Staff received training to ensure that their skills and knowledge remained up to date and the manager regularly supervised their work practice.

We found that although care needs were being met the care documentation was not detailed especially around physical and mental health needs. We also had some minor concerns about infection prevention and control practices, which were discussed with the provider and manager on the day of our visit.