Updated 26 May 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
One inspector carried out day one, and two inspectors carried out day two of the inspection.
Service and service type
Limetree House Upper Poppleton is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was a registered manager in post.
Notice of inspection
We gave a short period notice of the original IPC inspection due to the COVID-19 outbreak and measures that needed to be in place for our visit. Once the inspection was expanded to a focused inspection, we announced that we would be returning.
What we did before inspection
We contacted the local authority infection prevention and control team, safeguarding and commissioning teams for feedback and looked at information sent to us since the last inspection. We used the information the provider sent us in the provider information return prior to this inspection. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with five people who used the service and one relative about their experience of the care provided. We spoke with the registered and deputy manager, and briefly with a senior care staff.
We looked around the environment to review the facilities available for people and the cleanliness of the service.
We reviewed a range of records including multiple medication administration records, and two staff personnel files in relation to recruitment. We also reviewed a variety of records relating to the management and governance of the service.
After the inspection
We reviewed evidence that was sent remotely as well as seeking clarification from the registered manager to validate evidence found. We looked at audit and governance data, three peoples care plans, as well as infection prevention and control policies and procedures. We spoke by telephone with two people’s relatives, and a senior care staff.