The Limes

The Limes provides personal care and accommodation, for up to 55 younger and older people some of whom are living with dementia. The building consisted of two floors. At the time of the inspection there were 40 people living at the service. 35 people were present in the home during our visit, with another five in hospital.

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

Quality assurance systems were not always effective at identifying areas for improvement and did not always ensure people received safe care. Incidents were not always notified to the CQC as required. Government guidance and the provider’s own policies had not always been followed to ensure people were consistently kept safe. Lessons had not always been learnt when things had gone wrong.

Whilst people had not come to any harm, we found the management of people’s medicines required strengthening. Some guidance was missing for staff and storage was not always safe. Other risks, such as risk associated with people’s mobility and health conditions to people were assessed.

The provider had failed to ensure there were robust systems to check the suitability of agency staff. However, permanent staff were recruited safely. There was also mixed feedback about staffing levels, however we observed people did not have to wait for support.

People, relatives and staff felt positively about the management and felt supported. They were asked for feedback about the service. The provider and registered manager worked in partnership.

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

Rating at last inspection

The last rating for this service was requires improvement (report published 18 April 2020). You can read the report from our last comprehensive inspection by selecting the 'all reports' link for The Limes on our website at www.cqc.org.uk.

Why we inspected

The inspection was prompted in part due to concerns received about infection control, supporting people with risks to their health and management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Limes on our website at www.cqc.org.uk.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We identified two breaches. We identified breaches in relation to the management and oversight of the quality and safety of the service and in relation to notifying us of certain incidents.

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

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The provider has already provided us an action plan about 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Limes provides personal care and accommodation, for up to 55 younger and older people some of whom are living with dementia. The building consisted of two floors. At the time of the inspection there were 50 people living at the service.

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

People’s care files were not up to date to advise staff accordingly how to meet people’s needs. Care files were not clear around people’s level of capacity. People did not always have mental capacity assessments (MCA) or best interest meetings completed. People were at risk of been supported inconsistently by staff who were not clear on their capacity.

Staff spoken with did not always have a clear understanding of MCA or Deprivation of Liberty Safeguards (DoLS) legislation. Staff could not always identify which people were subject to DoLS in the home and how this application would restrict their liberty. People were at risk of not been supported in accordance with their needs.

The principles of the MCA were not consistent. The registered manager had carried out mental capacity assessments for some people, however there were not best interest decisions to support staff when providing care for people.

Applications were made to the local authority for DoLS. However, some of the applications were refused as these people did not lack capacity to understand decisions about their care.

The provider quality assurance system had failed to identify that people’s mental capacity assessments were incomplete or there were best interest decisions to support staff when providing care for people.

We found that people’s risks were managed effectively. Risk assessments demonstrated that people’s identified risks had been assessed and were being managed safely and reviewed regularly.

People felt staff knew them well and supported them to express their needs and wants. People told us that staff treated them with dignity and respect, where all personal care was carried out behind closed.

Complaints were managed in a robust way and appropriate investigation and action had taken place.

People’s communication needs were clarified through the assessment process and staff adapted their approach to ensure people with additional needs could access the information required.

The registered manager completed a month events analysis of the service, that focused on compliance issues. An improvement action plan was then devised to assist with the development of the service.

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.

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

Rating at last inspection

The last rating for this service was requires improvement (report published 13 March 2019)

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the effective sections of this full report.

Enforcement

We have identified one breaches. The service was in breach of Regulation 11 (need for consent).

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

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

The Limes is a residential care home that was providing personal care to 38 people at the time of the inspection. People who used the service had physical disabilities, sensory needs and mental health needs; such as dementia.

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

People’s experience of using this service:

Improvements were needed to ensure the newly implemented systems in place to monitor the service were imbedded and sustained. Improvements were needed to ensure records were updated in a swift manner.

We recommended the provider seeks nationally recognised guidance to ensure information was consistently presented in a format to aid people’s understanding.

People were supported by safely recruited staff who had the skills and knowledge to provide safe and effective support. People were supported to manage their risks, whilst promoting their independence. Systems were in place to ensure that people received their prescribed medicines. Effective care planning was in place which guided staff to provide support that met people’s needs, which were in line with their preferences.

People consented to their care and were supported in their best interests. The provider has systems in place to ensure that people’s capacity was assessed in line with the Mental Capacity Act. People were supported to eat and drink sufficient amounts in line with their assessed needs. People’s diverse needs had been planned for, which ensured people received individualised care in all aspects of their life. Professional advice had been sought and acted on to ensure people’s health and wellbeing was maintained.

Staff were kind and caring towards people and promoted choices in line with individual communication needs. People were treated with dignity and their right to privacy was upheld.

People had opportunities to be involved in activities both within the service and in the community. People and their relatives were involved in the planning of their care, which meant people were supported in line with their preferences. Complaints systems were in place, which people and relatives knew how to use. There was no one receiving end of life care at the time of the inspection. However, people’s advance decisions were planned.

There was an open culture within the service, where people and staff could approach the registered manager who acted on concerns raised to make improvements to people’s care. Feedback was gained from people who used the service.

Rating at last inspection:

Requires Improvement (report published 13 July 2017).

Why we inspected:

This inspection was carried out to check the provider had made improvements since the last inspection.

At the last comprehensive inspection in May 2017 the service was rated requires improvement overall (in the key questions of Safe, Effective, Caring, Responsive and Well Led). There was a breach in regulation because people were not always safeguarded from potential harm. We asked the provider to forward an action plan to show how they planned to make improvements to people’s care.

At this inspection improvements had been made to meet the regulations. However, some further improvements were still needed in the key questions of Safe and Well Led. The service had met the characteristics of Good in Effective, Caring and Responsive. Therefore, the overall rating is Requires Improvements.

Follow up:

We will continue to monitor the service through the information we receive.

The Limes provides accommodation and personal care for up to 41 people. People who used the service may have physical disabilities and/or mental health needs such as dementia. At the time of the inspection 37 people used the service.

There was a registered manager in post. 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.

People were not being safeguarded from potential abuse as incidents of suspected abuse had not been referred to the local authority for investigation. We raised a safeguarding referral for two people following our inspection. Following the inspection the registered manager took action to prevent further incidents.

Risks of harm to people were not always assessed and minimised. Action was not taken to reduce the risk of harm following incidents that had put people at risk or resulted in harm. People's risk assessments were not consistently followed to keep people safe.

The principles of the Mental Capacity Act (MCA) 2005 were not consistently followed. People's mental capacity was assessed, however precautions were not being taken to ensure any restrictions in place for people were the least restrictive option.

Staff felt supported and received training to fulfil their roles. However the training available was not always sufficient for the provider to be sure that staff were fully competent in the care tasks they were required to undertake.

People were not always treated with dignity and respect and people's changing needs were not always responded to in a timely manner.

The systems the provide had in place to monitor and improve the service were not consistently effective in identifying concerns and making improvements to the quality of care for people.

There were sufficient numbers of staff to meet the needs of people who used the service. New staff were recruited through robust recruitment procedures to ensure they were fit to work with people who used the service.

People's medicines were stored, managed and administered safely by trained staff.

People were encouraged to maintain a healthy diet and their nutritional needs were met. People were referred to health professionals if they experienced difficulties with eating and drinking. If people became unwell they were supported to access a range of health care services.

There was a range of hobbies and activities available to people if they chose to join in. People were involved in the planning of their care and activities through regular reviews and meetings and they were encouraged to be as independent as they were able.

People felt able to complain and confident that their concerns would be dealt with. The provider had a formal complaints procedure which was available for use.

People's feedback on the service was gained and action was taken to improve the quality of service where improvements were identified.

People who used the service and the staff felt the management were approachable and they were regularly asked their views on the service.

During this inspection we spoke with staff, the registered manager and viewed records. We also spoke with the Infection Control Team and the Environmental Health Officer.

We found that the provider had made improvements to their systems to prevent, detect and control the spread of infection.

The provider had commenced refurbishments to the environment to ensure that people were protected against the risk of infection and cross contamination.

The standard of general cleaning and hygiene practice in the home provided a clean environment. A number of practical steps had been taken to address the daily risks of cross infection. There were some wider premises issues that needed to be assessed and responded to in support of the effective management of infection control.

A number of improvements in the management of the home were also identified. Some of the staff shift patterns had been amended and additional staff had been recruited to provide more flexibility in meeting staffing needs. We also found that clear standards for recording had been set and were being followed in the home by staff.