Limetree House Upper Poppleton

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 requires improvement. At this assessment the rating has changed to good.This meant people were safe and protected from avoidable harm.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.A system was in place for the reporting of safety concerns and staff knew their roles in helping to keep people safe. Safety events were analysed by the registered manager and learning was shared across the staff team via team meetings and huddles. More work was needed to improve the recording of safety checks after an incident had occurred, however the registered manager took feedback onboard during the inspection and implemented a new recording procedure.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.Relationships had been built with other health care providers to ensure people had access to the services they needed, this helped to monitor people’s health and wellbeing. For example, the service held a GP round weekly and district nurses attended the service daily. People had healthcare passports which could be created from the new electronic care planning system, ensuring up to date and relevant information was shared with healthcare providers when needed. This also ensured a smooth transition from care home to hospital for those when their health deteriorated.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Clear systems were in place to safeguard people. Staff told us they knew how to raise concerns, and they were confident managers would deal with these concerns appropriately. The registered manager had oversight of safeguarding concerns and worked well with the local authority to resolve any issues identified. The registered manager understood their responsibility when depriving someone of their liberty to keep them safe. The correct applications were in place when needed to help safeguard people, these are known as Deprivation of liberty safeguards (DoLs). An independent professional who works with the service told us, “They [Staff] are responsive and have a very good grasp of the mental capacity act, and DoLS. This includes adhering to conditions of the DoLS.”

The provider worked with people to understand and manage risks by thinking holistically. Staff delivered care that was safe, supportive, and helped people engage in activities important to them. However, further improvements are needed to ensure that records fully reflect the care provided and demonstrate effective risk management.

People’s risks were managed well, and staff could tell us how they kept people safe, however we found that the checks taking place to evidence safety were not well recorded. For example, staff would check on people during the night to ensure they were safe, but they did not record the time and intervals that these checks were taking place. Due to this, we could not be certain staff were completing the checks when needed. The registered manager worked quickly to address this during the inspection and implemented new safety checks to improve the recording within daily notes.

Risk assessments were in place, but these would benefit from expanding to clearly show all mitigation that is in place to keep people safe. Again, the registered manager reviewed and began to improve these during the inspection. People had not been affected due to these concerns; families told us they felt their relatives were safe within the service. One person said, “I think [relative] is 100 percent safe there and it has given the whole family piece of mind.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.The service had a homely feel, and people were given the opportunity to choose décor which suited their personal preferences. Regular checks were taking place of the environment and equipment to help keep people safe and there was a system in place to report any maintenance concerns. Parts of the service needed updating; however, the provider was continuing to refurbish the property. We discussed with the registered manager guidance available to best promote a dementia friendly environment, which was taken onboard at the time of the inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing requirements were monitored by the registered manager who reviewed peoples care needs on a regular basis. People told us there were enough staff to provide unhurried, safe care. One family member said, “I think it is always well staffed. I don't think that the residents have to wait for anything at Limetree and the care is definitely good.’

Training was provided to staff to ensure they were skilled in their roles and support was provided by regular supervisions and observations to help staff learn and develop. Recruitment procedures and checks were robust to ensure potential staff were suitable to support vulnerable people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service was clean, with daily cleaning provision in place to reduce the risk of infection. Checks took place on a regular basis to help ensure the service remained of a good standard. People told us they found the service to be clean. One family member said, “[Relative’s] room is lovely and is a nice size and is always clean. Fresh bedding and towels every day.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medication as prescribed by staff who were trained to do so. There was a system in place for the safe storage, ordering and disposal of medication. Audits were taking place by the registered manager to ensure safe medication management.