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The Limes Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 July 2021

About the service

The Limes is a residential care home providing personal and nursing care to 23 people aged 65 and over at the time of the inspection. The service can support up to 28 people.

The care home is in one building spread across two floors. There are 26 single rooms and 2 double bedrooms. All bedrooms have ensuite facilities with a shared lounge, kitchen and garden.

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

People did not always have risks in relation to choking, falls and medicines fully assessed and so there was not enough guidance for staff on how to support their needs in these areas.

People’s medicines were not all administered or recorded safely. Amounts of some medicines did not match the recorded stock and some people’s pain relief medicines were not administered as prescribed.

People’s home was not always kept clean as there was food on the floor in one area and some cleaning required in a bathroom. Not all staff were wearing the correct face masks to help prevent the spread of COVID-19 and other infections.

There were no effective quality monitoring systems in place at the time of the inspection which meant that the standards of people’s care could not be assessed with a view to make improvements.

People’s care records had been transferred to an electronic system that was still being developed and so there were some gaps and inconsistency in records.

However, people told us they felt safe and they were happy living at the home. They said that staff were caring and patient and treated them well. People said the food was good and they had choices in what they ate and how they spent their time.

Staff had received training in safeguarding and other relevant topics and were in the process of receiving refresher and specialised training. This included Dementia awareness, Deprivation of Liberty Safeguards for people living with Dementia, nutrition and infection prevent and control.

Staff had a good understanding of how to act in emergencies and how to safeguard people. They were confident about reporting any concerns both inside and outside of the organisation.

There was a new manager and deputy manager in post who people, relative’s and staff all felt were approachable and open and they could raise any issues with them. They felt there had been a lot of improvements made. They had confidence the actions being taken by the new manager were positive and they would ensure all concerns were addressed.

We have made a recommendation about the management of staff rotas, recruitment procedures and infection prevention and control measures.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 04 May 2018).

Why we inspected

We received concerns in relation to risk management of person to person abuse, falls, eating and drinking and pressure care. Also, appropriate reporting and recording of incidents, staffing levels, staff skills, adherence to follow guidelines from health professionals and the general management of the service. 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.

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 improvements. 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.

The manager was aware of the areas that required improvement. The manager had created an action pla

Inspection areas


Requires improvement

Updated 15 July 2021

The service was not always safe.

Details are in our safe findings below.



Updated 15 July 2021



Updated 15 July 2021



Updated 15 July 2021


Requires improvement

Updated 15 July 2021

The service was not always well-led.

Details are in our well-led findings below.