The Limes Retirement Home

The Limes Retirement Home is a residential care home providing accommodation and personal care for up to 26 people. The service provides support to some people who were living with dementia. At the time of our inspection there were 24 people using the service.

The service provides personal care to people living in one adapted building and two of the bungalows on site. There are other bungalows on site, the service is not permitted, under their registration, to provide any personal care support to the people who live in them

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

The provider had improved the systems to identify risks and guide staff in how to mitigate them to reduce the risks of avoidable harm and abuse. Where an incident had happened, the provider had put systems in place to reduce them happening again.

Staffing levels were being kept under review and recruitment of staff was done safely. Medicines were being managed safely and people received their prescribed medicines. The service was clean and infection control systems reduced risks to people. Government guidance was followed in relation to the COVID-19 pandemic, including supporting people to have visits from family and friends.

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.

People’s care plans had improved and further development in this area was ongoing. The care plans included information to guide staff on how people’s needs were being met, including their end of life decisions. People were able to participate in activities to reduce the risks of boredom. There was a complaints procedure in place.

The provider had made improvements since our last inspection which were ongoing. The provider had accepted the support from the local authority to develop the service, including workshops for staff in recording. The service was monitored by the management team to identify and address any shortfalls.

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 15 May 2021) and there was breach 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.

At our last inspection we recommended that the provider assessed the staffing levels at night in line with people's dependency needs to ensure they were receiving the care they needed in a timely way. At this inspection we found the provider had assessed the night routines for staff and made changes in night staff duties to improve.

Why we inspected

The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to investigation. As a result, this inspection did not examine the circumstances of the incident. However, we did review how the provider had learned from the incident and systems put in place to reduce future incidents.

The inspection was prompted in part due to concerns received about recording, seeking emergency support and oral care. A decision was made for us to inspect and examine those risks.

We found the provider had taken action to mitigate risks to people using the service. Please see the Safe and Well-led sections of this full report.

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.

We undertook a focused inspection to review the key questions of Safe, Responsive and Well-led only. 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 based on the findings of this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Limes Retirement Home is a residential care home providing personal care to up to 26 older people in one adapted building and two of the bungalows on site. There are other bungalows on site, the service is not permitted, under their registration, to provide any personal care support to the people who live in them. At the time of our inspection visit on 8 April 2021, there were 24 people using the service, some of these people were living with dementia.

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

People’s care records were not always being kept up to date to reflect the care and support needed and preferred or to guide staff on how risks were mitigated. We had identified shortfalls relating to records at our last inspection and were assured at that time improvements were being implemented, enough improvements had not been made at this inspection. There is a breach of regulation relating to this.

Despite no concerns being raised relating to staffing levels from relatives and staff. We were concerned during the night, there was a risk of people’s care needs not being met in a timely way. We have recommended the provider assess the staffing levels at night. The registered manager told us they have obtained a dependency tool to help calculate the staffing numbers and a quote for a new call bell system had been received to assist them to monitor call bell response times.

People were receiving their medicines as prescribed. Systems were in place to reduce the risks to people relating to their medicines.

The service was clean and hygienic, and systems were in place to reduce the risks of infection. Relatives and a health care professional told us how the service had worked hard during the pandemic and kept the people using the service safe.

There were systems to gain feedback from the people using the service and relatives and this was listened to and acted on.

We received positive feedback about the care provided from people’s relatives, a person using the service and health care professionals. The provider told us they had good relationships with other external professionals involved in people’s care.

The provider was engaging with the local authority and accepted support relating to improving care records and the provision of workshops to staff, including in safeguarding and recording. Staff were trained in safeguarding and understood when concerns of abuse should be reported and to who.

Staff and relatives were complimentary about the registered manager. Staff told us about how supportive the registered manager was.

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 (published 9 June 2018).

Why we inspected

We received concerns in relation to safety, risks associated with pressure ulcers developing and people’s care records. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 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.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full 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 Retirement Home 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 monitor the service. 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 have identified a breach of regulation in relation to the management of people’s care records at this inspection.

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.

There was a registered manager in post, who was also one of the provider’s directors. 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 our last inspection of 26 May 2016 the service was rated Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

However, improvements were needed in how the service maintained person centred care plans to demonstrate how people’s individual needs were planned for and met, including their end of life care plans. The service was in the process of reviewing these and they had accepted the support of the local authority, but these improvements were not yet fully implemented. Discussions with staff identified that they knew about people’s needs, which reduced the risks to people receiving inappropriate care. As a result the key question for Responsive is now rated Requires improvement.

People had the opportunity to participate in group activities. However, some people felt that there was limited provision of more individual activities and interaction. There was a complaints procedure in place.

The service continued to provide a safe service to people. This included systems designed to protect people from abuse and avoidable harm. Staff were available when people needed assistance. The recruitment of staff was done safely. The service was clean and hygienic. People received their medicines safely.

The service continued to provide an effective service to people. People were cared for by staff who were trained and supported to meet their needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People received care and support to maintain a healthy diet and good health. People were supported to access health professionals where needed. The environment was suitable for the people living there.

The service continued to provide a caring service to people. People had good relationships with the staff. Staff interacted with people in a caring manner. Staff respected people’s views, listened to their choices and acted in accordance with their wishes.

The service continued to provide a well-led service to people. The service had a quality assurance system to monitor and assess the service provided to people. These systems assisted the registered manager to identify and address shortfalls promptly. As a result the quality of the service continued to improve.

Further information is in the detailed findings below.

There were 26 people living in the service when we inspected on 26 May 2016. This was an unannounced inspection.

There was a registered manager in post, who was also a provider. 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.

There were procedures and processes in place to ensure the safety of the people who used the service. Risk assessments provided guidance to staff on how risks to people were minimised. There were appropriate arrangements in place to ensure people’s medicines were stored and administered safely.

Staff were available when people needed assistance, care and support. Staff recruitment procedures ensured that new staff coming to work in the service were suitable for their role and people were safe. Staff were trained and supported to meet the needs of the people who used the service.

Staff had good relationships with people who used the service and were attentive to their needs. Staff respected people’s privacy and dignity and interacted with people in a caring, respectful and professional manner. People, or their representatives, were involved in making decisions about their care and support.

The service was up to date with the Mental Capacity Act (MCA) 20015 and Deprivation of Liberty Safeguards (DoLS).

People’s nutritional needs were assessed and met. People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment.

People were provided with personalised care and support which was planned to meet their individual needs. People were provided with the opportunity to participate in activities which interested them. A complaints procedure was in place. People’s concerns and complaints were listened to, addressed in a timely manner and used to improve the service.

There was an open and empowering culture in the service. Staff understood their roles and responsibilities in providing safe and good quality care to the people who used the service. The service had a quality assurance system and shortfalls were addressed promptly. As a result the quality of the service continued to improve.

Is it safe?

We spoke with four people using the service. They told us they felt happy, safe and they felt confident to report any concerns. One person said, 'I am very happy here.' The relatives we spoke with also said that they felt their family members were cared for in a safe way. One relative said, ' I am very happy that my family member is here. The staff look after them very well.' Records showed that assessments of any potential risks to people had been carried out and measures put in place to reduce the risks.

There were effective systems in place to reduce the risk and spread of infections. Staff we spoke with were knowledgeable and clear about their responsibilities with regard to cleanliness and infection control. This meant that people were protected from the risk of harm.

Although we found that medicines were generally managed safely we noted during our inspection that the manager had not undertaken competency assessments of the staff who administer medication at the service. This meant that they did not have a system in place to monitor that staff were administering medicines in a safe way. The manager informed us they had initiated medicines competency assessments immediately following our inspection. They emailed us with a copy of an assessment which they had undertaken.

The provider had recently arranged training for staff to understand the implications of the Mental Capacity Act (MCA) 2005. Documentation in the care records did not show that the staff had been recording when a decision had made on behalf of a person who lacked capacity. The Mental Capacity Act is a law which requires an assessment to be made to determine whether a person can make a specific decision at the time it needs to be made. It also requires that any decision made on someone's behalf is recorded, including the reasons why it has been made, how the person's wishes and preferences have affected the decision and how they were involved in the decision making process.

Is it effective?

Our observations showed that staff members knew people's individual health and support needs. We saw that people had a positive relationship with the staff who supported them. Staffing levels were satisfactory to meet the needs of people who lived at the home and we saw that there were sufficient skilled and trained staff on duty to meet the needs of people who used the service.

Is it caring?

People got on well with the staff,who supported them with respect but also in a friendly manner. The relatives we spoke with all said that the staff were very caring to their family members .Relatives also said that staff treated them well when they visited. One person's relatives said,' We visit here often. The staff always offer us a cup of tea. The staff look after our relative very well and we can see that they treat other people's relatives in a kind way too.' We saw that personal care was offered and delivered discreetly so that people's privacy and dignity was respected. The staff we spoke with said that they enjoyed their work and they demonstrated a good understanding of the needs of people who lived at The Limes.

Is it responsive?

People's needs and care plans were regularly reviewed by the staff and management at the home. Referrals were made to health professionals to ensure that people received appropriate support from people with the most appropriate knowledge and skills. Support plans included information on people's likes and dislikes and their preferences, to ensure care and support was delivered taking into account people's preferences. People participated in a range of activities of their choice and were encouraged to participate in activities within the local community. There were enough qualified, skilled and experienced staff to meet people's needs.

Is it well-led?

The staff told us that they felt well supported by the management team and trained to do their job. People we spoke with who lived at the home, relatives and health professionals, all told us that they felt the home was well-managed. The provider had some effective quality assurance and audit systems in place to monitor aspects of the service. Other important quality assurance and audit systems were not in place and some paperwork was not fully in order. Some staff had received supervision and appraisal meetings. The date on which some of these meetings had taken place was not clear. Some staff had not been offered regular supervision and appraisals.

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

People told us that before they received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. One person said, "We have lots of choice." Another person said, "It is always good here."

We spoke with three relatives of people who used the service. They told us that they were happy with the service that their relatives were provided with. One person's relative said, "No complaints what so ever. Very good. (Relative) is perfectly happy here." Another person's relatives said, " Staff are very good. Can't fault them. (Relative) is happy here."

We looked at the care records of three people who used the service and found that people experienced care, treatment and support that met their needs and protected their rights. We found that the provider had effective recruitment processes in place.

We found that the provider had taken reasonable steps to ensure that the premises were safe and suitable for people to live in.

We found that the provider had good quality assurance processes in place to continually monitor the service delivery and ensure that the service was well managed. We found that the service was well led.

We looked at care records including people's care plans. We found these detailed people's daily routines and their preferences including comprehensive information regarding night routines.

We spoke with four staff who said they were well supported and had received a range of appropriate training appropriate to their role.