Lime House

Updated 15 October 2025

Date of Assessment: 11 to 24 November 2025.

This service is a residential care home providing support to older people. At the time of the inspection 26 people lived at the service.

We carried out this comprehensive assessment in response to concerns about the quality and safety of care people received.

The provider’s systems for investigating, reporting, and learning were not robust, and appropriate actions were not always taken in response. Various concerns around the safety of people’s care, including health and safety, infection prevention and control (IPC) and medicine concerns were found during the inspection.

We were unable to determine if people had received appropriate care or not as the provider’s oversight and monitoring systems were not robust. During the inspection, we found concerns around whether people received appropriate care around their personal care, oral hygiene, repositioning needs and night checks.

Quality and safety in the service had not been maintained, and oversight and monitoring systems related to risks were not robust. Moving and handling practices were unsafe.

Systems to monitor staffing levels were not robust. The provider did not have systems in place or use a dependency tool to determine safe staffing levels at the service.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. There was limited evidence that people were involved in their care planning and reviews.

Staff were kind, respectful and caring.We observed staff engage with people in a friendly and caring manner and their conversations with people were good natured. People’s privacy and dignity were respected.

We were not assured person-centred care was always provided to people. Care plans lacked person-centred details and there were inconsistencies in care records. The service predominantly supported people living with a diagnosis of dementia and there was a lack of dementia support, dementia friendly signage and visuals in the service to meet people’s needs. Activities for people to engage within the service were limited.

Governance systems were not robust. Some of the health and safety and IPC concerns were found via the provider’s auditing systems in August 2025 and September 2025, however, timely action had not been taken to address the concerns and issues remained during our inspection.

The service was in breach of legal regulations in relation to person-centred care, good governance and staffing.

Updated 15 October 2025

Feedback from people and their relatives was mixed. Some people and their relatives were happy with the level of care provided, whilst others had concerns. One person told us, “I do like it here. All the staff are very helpful. They [staff] are usually quick if I need anything. The food is nice and I get enough drinks. I only have to ask, and they [staff] will get me what I want. The staff do seem to be good at their job.” However, a relative told us, “They [staff] were not taking care of [relative’s] personal hygiene. All the shower gels and toothpaste we bought [relative] were unopened. [Relative’s] bedding and the floor were minging. [Relative] was always in their room.”

People provided mixed feedback around staffing levels. Comments included, “The staff are alright. There are usually enough apart from busy times, they could probably do with a few more staff” and “Anything that you want at any time, you can ring the bell, and normally someone [staff] will knock on your door in a few seconds, quick as they can make it, they do come to you fairly quickly.”

Despite the mixed feedback, we found the service was not operating to the standard we would expect in many areas, and the service failed to assess, monitor and mitigate the risks relating to the health, safety and welfare of people.