The Limes Residential Home

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• 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

Our rating for this key question remains good. The service ensured falls risks were appropriately identified, assessed and mitigated. This included during the pre-admission process. Staff understood people’s risks and supported people safely. The scores for this area have been combined with scores based on the rating from the last inspection.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt safe. Relatives confirmed they were informed of any accidents, incidents and falls and were satisfied with how these were managed.

Staff understood and followed the provider’s falls policy and procedure and talked us through how they would support a person safely after a fall. Staff understood their responsibilities to report and record accidents, incidents and falls. They confirmed information and learning was shared through handover meetings.

Further work was required to fully embed an effective system to review and analyse falls at the service. This would ensure action was taken and lessons were learned where themes and trends were identified. During our assessment the service was in a period of transition to a new digital care planning system. Falls were individually reviewed, however there was a lack of documentation to demonstrate an overall analysis of falls at the service. Following our on-site visit, the registered manager brought forward the transition of falls onto digital system and completed 1 month’s review of falls and shared this with us. We found the new way of working to be more robust, and allowed a more in-depth analysis looking at themes and trends which would support in improving safety.

Overall, people told us they felt supported to transition safely into the service. One person told us the reason they had moved was due to them falling at home. They explained whilst they would prefer to be at home, they felt that the risk of falls was better managed at the service as they had not fallen at all.

The registered manager completed pre-admission assessments, which considered risk of falls. They explained they would ensure suitable mitigation was in place on admission to reduce the risk of falls. This included replicating the layout of people’s previous bedroom, ensuring beds and furniture were in the same place. They reported this had been a successful action to not only reduce the risk of falls, but supported people to orientate and have a smoother transition period.

Referrals to relevant professionals were made appropriately.

A pre-admission assessment process was in place and completed prior to people moving into the service and reviewed 72 hours after admission. This involved feedback from people, their families and relevant professionals. It reviewed falls risk and considered falls history.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us staff knew them well and supported their risks safely. They confirmed they had access to specialist equipment, such as sensor mat’s, call bells and walking aids

The registered manager explained they were involved in the writing and reviewing of people’s care plans and risk assessments. They told us this was in partnership with people and their families. During our assessment the service was in the process of transitioning to a digital care planning system, with plans to ensure people and their relatives can access their care plans on the system. Staff demonstrated a good understanding of people’s risks in relation to falls. They confirmed they were able to feedback into risk assessments if they observe changes in people’s needs. Staff told us they had regular competency checks in relation to how to support someone after a fall.

People were supported in line with their risk assessment guidance. For example, walking with the support of 2 staff. People had access to specialist aids and equipment, and these were kept in good condition. Adaptations were made where falls risks were identified. This included lowered beds, cushioning on sharp corners and ramps for wheelchair access.

Suitable care plans and risk assessments were in place for people who were at risk of falls. These clearly identified any equipment or assistance people needed to keep safe. Relevant policies were in place to support staff in managing falls.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.