Lime House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to governance and processes failed to effectively monitor and mitigate the risks relating to people's health, safety and welfare, as well as failing to ensure robust processes were in place to ensure sufficient numbers of staff were deployed.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive culture of safety. They did not take timely action to address concerns about safety and did not monitor and mitigate risks related to safety effectively. Lessons were not learnt to continually identify and embed good practice.

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. Some of these concerns were already known by the registered manager and provider, however, timely action had not been taken to address the safety concerns and the concerns still remained during our inspection. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had systems in place to review and investigate accidents and incidents. Staff managed accidents and incidents safely and systems were in place for recording events.

The provider worked with people and healthcare partners to establish and maintain safesystems of care. They made sure there was continuity of care, including when people moved between different services.

People’s needs were assessed prior to them moving into the service. Information of care needs assessed by the local authority and information from initial meetings with people were used to inform people’s care plans and risk assessments. Care plans also informed staff of external support input from health professionals such as support from community health care teams.

Processes were in place to ensure people received continuity of care, for example, when people were admitted to hospital for a period of time.

The provider did not work well with people to understand what being safe meant to them and how to achieve that. They did not concentrate on risk, avoidable harm and neglect, and failed to identify shortfalls in people’s care.

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. We reviewed several people’s care records and found vast gaps in records which we needed to safeguard, and these concerns were not picked up by the registered manager or provider. One person told us, “I would like more showers. I put a request for a shower in this morning, however, it has not been possible this morning as they are booked up.” Relatives added, “They [staff] were not taking care of [relative’s] personal hygiene. All the shower gels and toothpaste we bought [relative] were unopened” and “[Relative] would like to have a shower in the morning and then one at night, but here [relative] only gets a couple of showers a week due to staffing shortages.” This contributed to a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not work well with people to manage risks appropriately. Staff did not provide care to meet people’s needs that was safe and supportive.

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. We observed a number of incidents of staff providing unsafe movement and handling of people. For example, we observed staff drag a dining chair whilst a person was sat in the chair and the person shouted, “You’re hurting me, stop pushing me.” During this observation, a senior member of staff whose role involved auditing and assessing care practice was present, witnessed the unsafe practice and did not intervene. We also observed staff using a stand aid and failing to apply the sling appropriately, and a care supervisor witnessing the unsafe practice and not intervening. This contributed to a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider had systems and processes in place that operated ineffectively and failed to assess, monitor and mitigate the risks relating to the health, safety and welfare of each person, which put people at risk of harm. We reviewed several records relating to the premises and fire checks and found vast shortfalls. For example, weekly fire extinguisher and blanket checks had not always been completed and no checks were in place for January 2025 to June 2025, and fire evacuation drills were scheduled to take place twice a year, and none had taken place in 2025. This contributed to a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not always make sure there were enough skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

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. Although the provider was aware a system was required and in the process of designing one, this was yet to be implemented. People and their relatives provided mixed feedback about staffing levels, some told us, “It is always very understaffed. I can never get hold of anyone”, “During busy times they [service] could probably do with a few more staff”, “They [service] are regularly short staffed” and “It takes a while for them [staff] to get to me.” A staff member commented, “Sometimes there is not enough staff which is an issue.” This was a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Recruitment checks were robust which ensured staff were suitable to work with vulnerable adults. Staff had the necessary safety checks in place before starting work. Staff completed an induction when they first started, and there were opportunities for supervision [one-to-one support sessions with their line manager]. A staff member commented, “The induction was fine, I also did shadowing [observing experienced members of staff].”

Staff had been trained on how to help people move safely, however, we observed unsafe practice from staff and we were not assured that staff were skilled despite training provided. We relayed this to the provider. The provider took action during the inspection, suspending the staff identified from moving and handling practices and re-booking them onto training courses. The provider also discussed embedding a competency assessment around moving and handling.

The provider did not manage the risk of infection effectively. They did not follow IPC processes and detect and control the risk of infection spreading effectively.

The provider had systems and processes in place that operated ineffectively and failed to assess, monitor and mitigate the risks relating to IPC which put people at risk of harm. We reviewed several records related to cleaning and maintenance of people’s rooms and equipment and found vast shortfalls. For example, daily domestic duties involved the cleaning of communal rooms, people’s bedrooms and beds, however, we were not assured cleaning took place regularly and checklists were not complete. Night staff were required to complete tasks related to cleaning the building and people’s wheelchairs, however, no checklists were completed over the whole of October 2025 and 29 days in September 2025. Relatives told us, “There have been problems keeping [relative’s] room clean” and “[Relative’s] bedding and the floor were minging.” This contributed to a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Quality and safety in administering medicines were not maintained, medicine monitoring systems were not robust and medicine records were not accurate, complete and contemporaneous. We observed care supervisors administering medicines to people and they did not follow best IPC practices related to medicines. Temperature checks for the medicines room and medicines fridge had not been maintained and there were vast gaps in records. The administration of prescribed thickeners was not recorded accurately after each use. The administration of prescribed creams was recorded via case notes on an electronic system, however, the case notes did not consistently record prescribed creams had been administered as needed. One person was receiving covert medicines (medicines hidden in food) and there was no evidence a pharmacy had been consulted around the administration of each of their medicines. This issue was also highlighted by an audit conducted in May 2025 by an NHS (Wigan) Care Home Pharmacy Technician, however, the issue still had not been resolved when we visited. This contributed to a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.