Lime Tree House Residential Home

Lime Tree House Residential Home is a residential care home providing accommodation and personal care up to 30 people. The service provides support to older people. At the time of our inspection there were 24 people living at the home.

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

There was a positive culture at the home. People were supported by staff who knew them well and understood their care and support needs and individual choices.

Assessments were completed before people moved into the home to ensure their needs could be met. Care plans were developed and regularly updated. These were person-centred and reflected the care and support people wished for and needed. Care plans contained clear guidance for staff and daily records were completed appropriately.

People’s nutritional needs were assessed and met. People were given choices of food and drink throughout the day. Specialist diets were provided when required. People were supported to maintain and improve their health. There were regular discussions with health and social care professionals.

Staff had the knowledge and skills to support people effectively. They received regular training and supervision. The home was well maintained and met people’s needs. People were involved in design and re-decoration choices.

Quality assurance systems had been developed. The registered manager had good oversight of the home and was aware where improvements and developments were needed.

The home was clean and tidy throughout, systems were in place to ensure people were protected from the risk of infection.

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 and update

The last rating for this service was requires improvement (published 9 August 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out unannounced comprehensive inspection of this service on 17 June 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Need for Consent and Good Governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Effective and Well-led which contain those requirements.

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 Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lime Tree House Residential Home on our website at www.cqc.org.uk.

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.

Follow up

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.

The home was clean and tidy throughout. There was a detailed cleaning schedule and this included regular cleaning of high touch points such as door handles and light switches. Housekeeping staff had a clear understanding of their responsibilities.

Staff had access to personal protective equipment (PPE) and were seen to be using and disposing of this appropriately. Staff had received infection control and specific Covid-19 training, including guidance for staff about how to put on and take off PPE safely. Regular testing for people and staff was taking place.

People were supported to maintain contact with their family and friends. Visiting risk assessments had been completed and there was information about people’s preferred way of contact. There was a visiting ‘pod’ and designated visiting area within the home. In line with government guidelines single named visits into the home had commenced.

People were also supported to maintain contact through telephone and video calls. Activity staff updated people’s families weekly, through email, about what people had been doing and what activities they had enjoyed.

All visitors were required to have their temperature checked and wear the appropriate personal protective equipment (PPE). Single named visitors were required to have a rapid Covid-19 test before the visit.

Lime Tree House Residential Home is a residential care home providing personal care to 29 older people at the time of the inspection, some of whom were living with dementia. The service can support up to 30 people.

Lime Tree House Residential Care Home accommodates people in one adapted building.

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

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The quality assurance framework was not always effective and had not supported staff to identify and address areas needing improvement. Care plans were not always clearly written and did not always include enough information for staff to support people safely and consistently. Care records were not always completed consistently to enable oversight of whether a person’s behaviour that challenged was increasing or decreasing. Feedback from people and stakeholders was not used to improve the service in a timely way.

Care plans varied in personalisation. This had been recognised by the registered manager who was in the process of reviewing and rewriting people’s care plans to make them more person-centred.

People told us they felt safe. There were positive relationships between people and staff and we saw them laughing and joking together. People were treated with kindness and care. One person’s relative said, “I am just extremely happy with it, it is a home from home.”

Staff supported and encouraged people to be independent where they were able. People’s needs were assessed before they moved into the home and their hobbies, interests and life stories were included in their care plans.

People were supported to eat and drink and make choices about their meals. People with specific needs around eating and drinking were supported safely.

There were enough staff available to meet people’s needs. Staff were supported with training and supervision. Staff told us they felt supported by the registered manager.

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 good (16 June 2017)

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified two breaches of regulation in relation to people’s consent and the governance of the service. The provider had failed to ensure that people were supported in line with the principles of the Mental Capacity Act 2005. The provider had failed to ensure that systems to assess, monitor and improve the quality and safety of the service were sufficiently robust.

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 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.

The service had a registered manager. 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 the last inspection on the 17 October 2016, the service was rated Good overall and Requires Improvement in the 'well-led' domain. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lime Tree House Residential Home on our website at www.cqc.org.uk

The service had improved their quality assurance framework. Care plans were now updated regularly and provided robust guidance for staff to follow. Fluid charts were now totalled at the end of each day and nutrition care plans had considered people’s daily fluid intake target.

Systems were now in place to mitigate the risks relating to health, safety and the welfare of people living at the service. Weekly health and safety checks were taking place and concerns raised at the last inspection in October 2016 uneven flooring had been addressed.

People, staff and relatives were complimentary about the leadership and management of the service. One staff member told us. “The manager is one of the best manager’s I’ve ever had.” A visiting relative spoke highly of the leadership style of the manager reflecting that they made themselves available and were visible within the service.

Forums were in place for people, relatives and staff to provide feedback on the running of the service. Feedback was then used to drive improvement and improve the quality of care that people received.

There was a friendly, warm and homely atmosphere and a positive culture. Staff described the key strength of Lime Tree House as its welcoming and friendly atmosphere. One staff member told us, “There is a strong family atmosphere here which I really enjoy.”

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.

The provider’s quality assurance framework was not consistently effective or robust. Shortfalls and omissions in documentation were evident. Risks associated with the environment had been identified but not acted upon, placing people at risk of falling.

People commented they felt safe living at Lime Tree House. People commented positively about the care, treatment and support received. One person said, "Yes, I have a safe room and the corridors are excellent.” A range of risk assessments were in place, however, the risk management of skin breakdown was not robust. We have made a recommendation about risk assessments.

Staff demonstrated good knowledge and understanding of the Mental Capacity Act (MCA 2005). One staff member told us, “We have to assume a person has capacity until proven otherwise. If a decision is made on their behalf it has to be in their best interest. People can make an unwise decision but it doesn’t mean they lack capacity.” However, mental capacity assessments were not completed in line with legal requirements. We have made a recommendation about the completion of mental capacity assessments.

Care and support was provided to people living with dementia, however, improvements were required to make the environment dementia friendly. We have made a recommendation about sourcing input from a national source on dementia friendly environments.

People we spoke with were complimentary about the caring nature of staff. People told us care staff were kind and compassionate. People were treated with respect when they received care. One person told us, “Staff are kind and caring at all times.” Dignity champions were in post and the registered manager worked with Skills for Care to promote awareness and understanding of the importance of privacy and dignity.

Systems were in place for the safe storage, administration and disposal of medicines. Records showed people received their medicines as prescribed and in their preferred manner. People had access to healthcare services to maintain good health.

People were protected from the risk of harm and abuse. Staff had received safeguarding adults training and were aware of their responsibility to report any concerns. Policies and procedures were in place to advice staff on what they should do if they had concerns. Safe recruitment practices were followed before new staff were employed to work with people.

People, staff and relatives were complimentary about the leadership and management of the home. A staff member told us, “I feel supported by the team I could go and ask any of the care workers or seniors or manager for help at any time. Everyone is so kind and supportive.”

Positive relationships had been developed between people as well as between people and staff. There was a friendly, caring, warm and relaxed atmosphere within the home and people were encouraged to maintain relationships with family and friends. A wide range of activities were available for people to participate in. One person told us, “I love the activities, quizzes are my favourite, we have been to Middle Farm, I like animals.”

People were supported to have sufficient to eat and drink. Where people required assistance this was done at a pace appropriate to them. Special dietary requirements were met, and people's weight was monitored, with action taken when required. People spoke highly of the food provided. One person told us, “Food has considerably improved, a new lovely chef who is very good and the other chef, plenty to eat and she comes round and makes her presence known every mealtime.”

During our inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered providers to take at the back of the full version of the report.

People's consent was sought appropriately. People told us, "They always make sure I consent before they do anything and I can always change my mind". We saw people's consent or refusal were recorded and care was delivered in line with their agreed care plans.

People experienced care, treatment and support that met their needs and protected their rights. A relative told us, "The care is very good here, my relative is well cared for, they are kind and patient towards her and got to know her well".

We found that people who used the service were provided with a choice of suitable and nutritious food and drink. One person told us, "The food is always hot, and it is often too much, but it is always tasty". A relative said, "My mother eats well here, the menus are good and all the food is freshly cooked".

The service had a safeguarding policy for the protection of vulnerable adults. Staff were trained appropriately and were aware of their responsibilities in respect of safeguarding. One member of staff said, "I would not hesitate in talking to the manager straight away if I felt any abuse was taking place, or to social services".

Staff received appropriate professional development and were appropriately supported.

Residents described the activities which were provided for them to participate in although one person told us 'I do not join in the activities I prefer to stay in my room with the door open, the staff often check on me and bring me a cup of tea, we have a chat',

When we asked people to describe the meals they told us how they were consulted and how their preferences were taken into account. The feedback we obtained was complimentary and included 'The food is superb, always hot and nicely presented, we can choose in advance what we prefer'.