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Lime Tree Gardens Requires improvement

We are carrying out a review of quality at Lime Tree Gardens. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 June 2019

About the service: Lime Tree Garden is a purpose-built care home for up to 24 adults with mental health needs. On the day of our inspection there were 23 people using the service. The aim of the service is to support people with enduring mental health illness to develop basic life skills so they can live independently in the community.

People’s experience of using this service:

Medicines were not always managed safely. People were supported to take medicines in line with their preferences, but the service’s processes to ensure that medicines were always administered as prescribed were not always effective.

People did not always receive personalised care. Their needs had been assessed by the service prior to receiving services. However, the care plans at times provided insufficient detail for staff to provide personalised, strength-based care and support that was consistent and responsive to people's individual needs. We noted that staff we spoke with had a good understanding of the needs of people they supported.

Staff received a range of training to help them to work with people who used the service. More training was required to guide staff on how to effectively work with people when they exhibited behaviours that challenged the service.

Staff received support in the form of one to one supervision and a yearly appraisal of their personal and professional development goals. However, supervisions were not always regular. Staff also participated in a range of meetings where they could discuss matters relating to caring for people and the service provision.

The service had checks in place but these had not identified shortfalls that were found during inspection. These related to the management of people's medicines, following the principles of the MCA, staff training and effective care planning and records keeping.

DoLS applications had been submitted when required. Improvements were needed in relation to what decisions individual people with no capacity could make and how staff could support them in doing so.

Improvements were needed to ensure that people’s needs had been thoroughly assessed before they were accepted as suitable to live at the service. This was to ensure people’s needs could be met by the service.

Some improvements were needed to how the service managed risk to the health and wellbeing of people using the service and health and safety of the premises. Accidents and incidents had been reviewed to ensure lessons were learnt and the safety of the service improved.

People were encouraged to be involved in planning and reviewing of their care through one to one meetings. However, because the meetings were not always recorded, the provider could not evidence that they had taken place.

External professionals gave positive feedback about the commitment of staff working at the service. They also thought the service was well led. However, they thought further work was needed so the methodology and the recovery approach used by the service was clearly defined and visible when supporting people who used the service.

Safeguarding concerns were managed promptly. Staff had received safeguarding training and were able to recognise when people were at risk of abuse.

Safe recruitment procedures helped to protect people from unsuitable staff. There were appropriate staffing levels to response to people’s need.

The service asked people’s consent before providing care and support to them. However, when people did not have capacity to make decisions, staff did not have enough information on how to support these people with making decisions about their everyday care.

People received support to have a diet that met their needs and preferences. People had access to health professionals when needed.

The accommodation provided people with space they could use to socialise or spend time on their own if they preferred. People could move freely between different parts of the service.

Staff protected people’s priva

Inspection areas


Requires improvement

Updated 15 June 2019

The service was not always safe

Details are in our Safe findings below.


Requires improvement

Updated 15 June 2019

The service was not always effective

Details are in our Effective findings below.


Requires improvement

Updated 15 June 2019

The service was not always caring

Details are in our Caring findings below.


Requires improvement

Updated 15 June 2019

The service was not always responsive

Details are in our Responsive findings below.


Requires improvement

Updated 15 June 2019

The service was not always well-led

Details are in our Well-Led findings below.