Limegrove

Limegrove is a residential care home providing accommodation and personal care for up to a maximum of 55 older people, some of whom may be living with dementia or other age-related conditions. The service is divided into five living areas over three floors. Each living area has its own lounge and dining room. At the time of inspection, 41 people were living at Limegrove.

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

Although some people told us staff responded to them in a timely manner when they required support and our observations supported this, staff told us they felt rushed and did not have time to spend with people. Staff rotas showed staffing levels fell below the amount they should be on several occasions. Although call bell audits demonstrated people’s bells were responded to in a timely manner, there was a risk that people may not receive prompt care from staff and staffing levels may be unsafe.

Risks to people had not always been identified or recorded in a way that may assist staff to provide responsive care. This meant people may be at risk of harm. In addition, some incidents of potential abuse had taken place, but these had not always been reported to CQC in line with requirements.

Although there were governance arrangements and systems at Limegrove these were not always effective in identifying shortfalls or areas requiring improvement. Such as care records or actions from audits. Staff told us, that despite a clearly recognised structure in place, they did not always feel supported or valued.

The registered manager was aware that work was needed to improve activities for people in order to help ensure they were not socially isolated. Our observations on the day were that little was going on and some people told us they would like to see more happen within the service. People said they spent their time in a variety of ways and the registered manager was working hard to reinstate activities following a recent COVID-19 outbreak.

People told us they were happy living at Limegrove. They said staff were kind and caring towards them and showed them respect. We observed this during our visit. People were enabled to make choices around how they wish their care and to retain their independence as much as possible.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were supported to see a healthcare professional when needed and they were provided with sufficient food and drink to help ensure they maintained a healthy weight. People received the medicines they required.

People lived in a service that was well maintained and homely and they were cared for by staff who had received sufficient training and supervision for their role. Staff knew people well and read people’s care plans to help ensure they provided person-centred, individualised care. People said they spent their time in a variety of ways and the registered manager was working hard to reinstate activities following a recent COVID-19 outbreak.

People knew how to make a complaint and felt comfortable doing so. Where complaints were raised, these were addressed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 14 August 2019).

Why we inspected

This inspection was prompted in part due to concerns received around poor infection control practices, lack of staff, poor medication records, a high number of falls within the service and people not receiving adequate drinks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

We have found evidence that the provider needs to make improvements, although we did not find anyone was at immediate risk of harm. Please see the key questions of Safe and Well-led of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We found breaches of regulation in relation to recognising potential safeguarding concerns, staffing and good governance within the service. You can read what action we have asked the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

• Relatives were encouraged to visit their loved ones, as an essential caregiver throughout any covid outbreaks to support people’s wellbeing by continuing to see their families.

• The service had adapted the environment by re-arranging furniture for people who found it difficult to understand the need to isolate. This helped to keep other people safe.

• The service had acquired some tablet devices through the government scheme to help people to keep in touch with family members when unable to visit. They had purchased headphones to use with the tablets for people who were hard of hearing. Staff supported people with these devices.

• Additional uniforms had been made available for agency staff to wear, on occasions where they may have worn their own on the way to work. This ensured that all staff changed into clean uniforms on arrival at the service, thus reducing risk of infection.

Limegrove is a residential home providing personal and care for people with aged related illness or who may be living with dementia. The service accommodates up to 55 people in one adapted building set out into five living areas. Each living area has its own kitchenette, dining and communal area. At the time of our inspection, there were 42 people living at the service.

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

People told us they felt safe living at Limegrove and they were looked after by staff who were kind and caring, showed them respect and knew them as people. People said they received the medicines they needed and they could see health care professionals when necessary.

People said the food was good and they were given choice. Throughout the day people were seen being offered sufficient nutrition and hydration to help keep them healthy. People said they felt safe and that there were sufficient staff on duty to attend to their needs.

There was the opportunity for people to attend activities both within and outside of the service and in addition, get involved in events taking place within the local area. People said they had the opportunity to raise any concerns, ideas or give their feedback on the level of care they received. The registered manager was felt to have made a positive impact on the service and listened to people and their views to make any improvements needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. People lived in an environment that was adapted for their needs and staff encouraged people in their independence and positive risk taking whilst keeping them safe.

Since the last inspection, robust governance processes had been introduced to help ensure the shortfalls we found in relation to medicines, risk assessments, recording keeping and following the principles of the Mental Capacity Act (2005) were picked up and addressed.

Everyone we spoke with – people, relatives and staff told us how good the registered manager was and how changes had been made for the better since they had taken over the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

For example: Rating at last inspection and update

The last rating for this service was Requires Improvement (published 24 July 2018) and there was a breach of regulation and three recommendations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Limegrove is a home that provides accommodation and personal care to up to 55 adults. People living at the home had physical disabilities and long-term health conditions. Most people at the home were living with dementia. At the time of our inspection there were 52 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was not present during our inspection and the service was being managed by an interim manager. The manager and the provider’s district manager assisted us with our inspection.

At our last inspection to this service in May 2017 we identified shortfalls in the governance of the service. This was due to a lack of registered manager and a lack of contemporaneous records held about people. We also made recommendations to the registered provider around staffing levels and medicines management. We used this inspection to check if these shortfalls had been addressed.

Providers should be meeting the standards set out in the regulations and display the characteristics of good care however, we identified some shortfalls within the service. People received the medicines they required, however we found some shortfalls with medicines management within the service. We have made a recommendation in this respect. Staff were aware of their responsibility to keep people safe and free from harm. However, there were inconsistencies in the records relating to people’s risks and staff was not always following guidance that was in place.

There had been a high number of falls at the service and the manager had started to address this by increasing the staffing levels. We did not see anyone having to wait for care on the day of our inspection.

People were supported by kind and caring staff. Staff communicated with people in a way that demonstrated understanding of their needs. People told us that staff were respectful and staff understood how to promote people’s privacy and dignity when providing care. People were supported to remain as independent as possible.

Appropriate checks were carried out when recruiting staff to ensure that they were suitable for their roles and the provider took steps to ensure that people were kept safe in the event of an emergency. People lived in an environment that was clean and hygienic and adapted to suit their needs.

Important information about people’s healthcare needs and medicines were recorded in their care plans. Staff worked alongside healthcare professionals to meet people’s health needs. Where any accidents, incidents or infections occurred, staff took appropriate action in response to them.

People’s needs were assessed before they moved into the service and these assessments formed the basis of a person’s care plan. People were provided with food that matched their preferences and ensured any dietary needs were met. Staff routinely offered people choices and involved them in their care. We found some missing evidence in relation to mental capacity assessments and best interests decisions in relation to the Mental Capacity Act (2005).

Staff received training appropriate to their roles and the provider’s values. Staff benefitted from supervision and appraisals. Although management responded to complaints received, the paperwork held in relation to complaints was not complete. We have made a recommendation to the registered provider in this respect.

Care plans included the relevant information about people and staff were knowledgeable about individuals and their likes and dislikes. No one was receiving end of life care at the time of our visit. However, there was a lack of end of life care planning evident in people’s care plans. We spoke with the manager about this and have made a recommendation.

People had access to a range of activities and there was ongoing work to recruit new staff to lead on these. There was a good atmosphere across most of the home throughout the day with people engaged in various past-times of their choice.

Regular audits and checks were carried out to ensure the quality of the care that people received. The provider routinely involved people, relatives and staff in decisions about the home. Staff felt supported and we received comments that things had improved since the interim manager had been at the service. The service worked with external agencies to look at new ways of providing a good service.

During our inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made four recommendations to the registered provider. You can see what action we told the provider to take at the back of the full version of the report.

This was an unannounced inspection that took place on 4 May 2017.

The home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The deputy manager assisted us with our inspection on the day.

We carried out this inspection to check the registered provider had taken action in relation to the concerns we identified at out inspection in March 2016. At that inspection we found breaches of regulation in relation to medicines, person-centred care, records and people not being shown respect by staff. Shortly after our inspection the registered manager left the service and since then the service has been without a consistent manager. The provider had implemented management support for the service which was overseen on a daily basis by the regional support manager, deputy manager and weekly visits by the district manager. We found at this inspection many of these areas we had identified had improved. This was mainly down to the hard work of staff and the newly appointed deputy manager. However, there was still further work to be done.

Although there had been a lot of work undertaken on reviewing people’s care records, this had not yet been completed and we found some people’s care records were not accurate or reflected people’s most current needs. We found records relating to medicines were not always completed as they should be. There was a lack of evidence that people were receiving their topical medicines (medicines in cream format) as they should because charts were not being completed.

Overall there was a sufficient number of staff on duty. However we have made a recommendation to the registered provider to review deployment of staff during break times.

There was a good atmosphere in the home where people and staff interacted in an easy-going manner. People and relatives were happy with the care provided and they were made to feel welcome when they visited. Staff supported people to take part in various activities although we have recommended the provider consider introducing more purposeful activities.

Where people had risks identified guidance was in place for staff to help reduce these risks, although some of these risks required updating as people’s health deteriorated. Staff were aware of their responsibilities to keep people safe and the registered provider carried out robust recruitment processes in order to help ensure only suitable staff worked at the home. Care was provided to people by staff who were trained and received relevant support from their manager.

The provider had good quality assurance process and checks were carried out by staff to help ensure the environment was a safe place for people to live and they received a good quality of care. Staff were involved in the running of the home as regular staff meetings were held. People were asked for their views about all aspects of their care and could make their own decisions.

Staff followed the principals in relation to the Mental Capacity Act 2005 and staff were heard to obtain people’s consent before they supported them. Where people had restrictions in place to keep them safe appropriate DoLS applications had been submitted.

People were provided with a choice of meals each day and those who had specialist dietary requirements received the appropriate food. Staff maintained people’s health and ensured good access to healthcare professionals when needed. For example, the doctor, dietician or district nurse.

Complaint procedures were available to people and there was a contingency plan in place should there be an emergency in the home or it had to be evacuated. It was evident staff had maintained a good level of care and had displayed commitment to ensuring people were looked after in a way they should expect during the absence of a consistent manager. The deputy manager had undertaken a lot of work since they had been recruited to address shortfalls in the service.

During the inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made three recommendations to the provider. You can see what action we told the provider to take at the back of the full version of the report.

This was an unannounced inspection which took place on 22 March 2016.

During our inspection the registered manager was present. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Safe medicines management procedures were not always followed by staff. Although risk assessments were in place for people, those suffering from particular medical conditions did not have risk assessments in relation to this. Care records held for people were not always completed fully and did not reflect their current level of needs.

Although staff knew people well and were able to describe to us people’s individual characteristics and routines, they did not always treat people in a thoughtful way. People may not always receive responsive care because staff did not always follow guidance included in care plans.

Although staff understood the Mental Capacity Act they had not always completed mental capacity assessments with people before making decisions on their behalf. However, where people did not have the capacity and were being restricted, staff had followed the legal requirements in relation to this.

People were cared for by a sufficient number of staff which meant they did not have to wait to be assisted. Staff understood their responsibility in relation to safeguarding people from abuse. When people had an accident this was recorded and accidents and incidents monitored to help prevent reoccurrence.

Staff had guidelines in place to help ensure people’s care and treatment continued with the least interruption possible, should the home have to be evacuated or an emergency stopped the service running.

Recruitment checks were completed to ensure permanent staff were safe and skilled to support people. Staff received an induction and on-going training to help ensure they were competent in their role. Staff supervision and appraisal took place in order to provide support to staff and they worked to best practice guidelines.

People had access to a range of meals as well as snacks throughout the day. People’s health was monitored and staff referred people to external health care professionals when needed.

People’s privacy was respected by staff and staff welcomed relatives into the home. There was a range of activities available to people which we observed people taking part in.

People were made aware of how to make a complaint should they feel the need to. People and their representatives were encouraged to give their feedback and feel involved in the running of the home.

Quality assurance checks were carried out in order to improve the service and actions identified were addressed by staff. Staff felt supported by the registered manager and were included in the running of the home through regular staff meetings.

During our inspection we found some breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made some recommendations to the provider. You can see what action we told the provider to take at the back of the full version of the report.

We found that people's nutritional needs were assessed when they moved into the home. Information about people's nutritional needs was communicated to the chef and referrals were made to specialists where necessary. People said that the food at the home was good and that they had opportunities to give their views about the food.

We checked a sample of staff files and found that the provider carried out appropriate checks before staff began work. At our last inspection there were not enough staff on duty to meet people's needs. At this inspection we found that the provider had increased the staffing hours. Whilst this had improved people's experience in terms of their care, people said that staff rarely had time to stop and talk with them.

People had opportunities to have their say about the service they received and the provider had systems in place to monitor the quality of service provision. The standard of record-keeping was generally good but we noted two issues that the provider may wish to note. Risk assessments relating to falls were not dated and two sections had not been completed in the majority of care plans we checked.