Lime House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of a legal regulation in relation to governance and processes failed to effectively monitor and mitigate the risks relating to people's health, safety and welfare.

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Due to the inconsistent oversight there was not a clear vision or culture within the service. Staff spoke about the difficulties the service recently faced, and although some changes had happened, struggles within the service remained. Comments included, “I would not recommend this care home, I feel like the care home is not run as well anymore.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity.

The registered manager and provider failed to assess, monitor and mitigate the risks relating to the health, safety and welfare of people. As discussed in the ‘safe’ domain, quality and safety in the service had not been maintained, and oversight and monitoring systems were not robust. Moving and handling practices were unsafe and this had not been picked up by the registered manager or the provider’s monitoring systems. Senior staff whose roles involved identifying bad practice were not competent and observed unsafe practices without intervention.

The provider fostered a positive culture where people felt they could speak up.

The service had a whistleblowing policy in place. Staff we spoke with told us they felt able to speak up about issues and their concerns would be listened to.

People and their relatives told us when they could raise concerns about their care and support when they needed to. They felt able to approach and speak with management and staff.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider’s recruitment process and internal processes meant staff were recruited fairly and workforce equity was promoted. The provider employed a wide range of staff with diverse backgrounds.

The registered manager understood the importance of having a fair and inclusive workplace. Staff received relevant training and supervision to support their knowledge and understanding of equality, inclusivity and fairness in the workplace.

Staff told us they felt they were valued and treated with respect.

The provider did not have clear systems and good governance. They did not act on the best information about risk, performance and outcomes.

Governance systems were not robust. Some of the health and safety and IPC concerns were found via the provider’s own 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. As discussed in the ‘safe’ domain, timely action had not been taken in relation to medicine concerns which were identified by an external agency in May 2025. The provider’s medicine audits were not robust and did not pick up on the issues we found in relation to prescribed creams, transdermal patches, thickeners and temperature recordings. Medicine audits had also not been completed consistently. Senior staff whose roles involved identifying bad practice were not competent. This contributed to a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had taken some action to address the concerns we raised during the inspection and other required actions informed their project plan to drive improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

In our review of people’s care records, conversations with the registered manager and staff, we found the provider was in contact with relevant health professionals to ensure people’s health needs were met.

Feedback from external social care professionals were positive. A social care professional commented, “The home has worked very closely with the local authority, social workers and customer relations team to support a complicated situation.”

The provider did not focus on continuous learning, innovation and improvement across the organisation. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice.

The providers did not demonstrate a responsive improvement culture and did not have robust systems to effectively monitor and mitigate the risks relating to people's health, safety and welfare. There was a lack of timely problem solving and action taken when things had gone wrong. Systems to review care plans were not effective as the provider had not identified errors, gaps and inconsistencies we highlighted during our inspection.This contributed to a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had taken some action to address the concerns we raised during the inspection and other required actions informed their project plan to drive improvements.