Archived: The Limes Residential Care Home

The registered manager had recently left the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Instead we were supported on the day by the Provider and the newly appointed deputy manager.

There were not always enough staff deployed in the service to consistently meet people's needs. People were left on their own for long periods of time without the support of staff. Not all of the care staff on duty provided care to people; some were undertaking kitchen and laundry duties which left one member of staff to provide the care for 13 people.

Risk assessments for people were missing and other assessments were not always detailed. There was not enough information to guide staff in how to reduce the risks to people. Incidents and accidents were not always recorded and those that were recorded lacked detail and actions put in place to reduce the risk of incidents. Staff were not following good infection control. There were aspects to the environment that were not safe for people including windows in a bedroom that did not open. The premises and equipment was not well maintained. However people’s medicines were managed in a safe way

Although staff and the provider had knowledge of safeguarding adult's procedures they were not putting this into practice. Safeguarding incidents were not always being reported to the local authority. There was a safeguarding adult's policy in place however staff were not following this. People who had capacity were having their liberties restricted.

People's rights were not always met under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had not been completed specific to the decision that needed to be made around people's capacity. DoLS applications had been submitted to the local authority around whether people's liberties were being restricted however these had also been submitted for people who had full capacity.

People were not always receiving care from staff who were competent, skilled and experienced. There was a risk that people were receiving care from staff who were had not had training to meet the needs of people with mental health issues or behaviours that may challenge others. Staff competencies were not always assessed as they did not have appropriate supervision or appraisals.

People at risk of dehydration or malnutrition did not always have effective systems in place to support them. People were not always provided choices that met their reasonable preferences. Where people's food intake needed to be recorded this was not being done even when people’s weights had fallen. People had not always have access to health care professionals to support them with their health needs in a timely way.

Staff at the service did not always treat people with dignity and respect. There were times where people were ignored for periods of time throughout the day and people's dignity was not always maintained. People were not always consulted about the care they wanted. The routines of the home were imposed for staff convenience rather than to meet the personal choices of people. We did see times when staff were caring and considerate to people and relatives did say that staff were caring to their family members.

People's preferences were not consistently being sought by staff. The provider was not always responsive to people's needs. There was no detailed information in people's care plans around the support they needed. There was a lack of detail around care for people with a mental health diagnosis.

There were not enough activities on offer specific to the needs of people. There were long periods of time where people had no meaningful engagement with staff. People that wanted to go out did not always have the opportunity.

There were not effective systems in place to assess and monitor the quality of the service. Although some audits had been undertaken these had not been used to improve the quality of care for people. Records were not always completed or accurate. Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The provider had not informed the CQC of significant events.

There was a complaints procedure in place however not everyone knew how to access this. Complaints were not always appropriately responded to.

Recruitment practices were safe and relevant checks had been completed before staff started work.

Personal evacuation plans were in place for every person who lived at the service. In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this time frame. If not enough improvement is made

within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service.

This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe with the staff. One relative told us they visited at a variety of times during the day and had never witnessed poor practice from the staff.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. The provider reported safeguarding alerts to the local authority and notified CQC. This reduced the risks to people and helped the service to continually improve.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore it did not put people at unnecessary risk.

The registered manager sets the staff rotas, they take people's care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helpeds to ensure that people's needs were always met.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. Relatives that we spoke with confirmed they had been involved in them when their relative were first admitted to the home and that they reflected their current needs. Relatives that we spoke with confirmed that although they were not always informed formally when the care plans changed staff always spoke to them and would notify them immediately of any changes.

The premises had been adapted to meet the needs of people with physical impairments.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. Comments received from relatives included 'Staff are lovely they are kind and caring. We are always welcomed to the home at whatever time that is.' 'When my family member was ill staff spent a long time sitting with her and encouraging her to eat and drink to avoid a hospital admission. We didn't want them admitted to hospital.'

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People benefitted from some activities in and outside the service regularly. We were told people liked to visit a local restaurant and go out for meals with staff or family.

People told us they knew how to make a complaint if they were unhappy. We looked at the complaints record and found there had been no complaints made to the provider. We saw the complaints policy displayed on the notice board. Relatives confirmed that they had not needed to make a complaint. People could be assured that if a complaint had been received there was a system in place which would ensure investigation and action.

Is the service well-led?

The service worked well with the local authorities that had placed people at the home. This ensured people received their care in a joined up way.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and that quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We spoke to people as they came to the dining room for breakfast. They told us they liked the food and enjoyed porridge. One person said 'I like a fry up.' We later observed that person eating a cooked breakfast.

The provider had developed care plans to ensure the care provided met people's needs. We saw that risks had been identified but had not been fully managed to protect the welfare and safety of people.

Staff had knowledge and had received training in safeguarding vulnerable adults.

We looked around the home and identified some shortfalls with the cleanliness and decoration. We also identified areas where hand wash was not available for staff and equipment was soiled and dirty.

The provider had followed recruitment procedures which meant suitable staff were employed by the home.

Staff received regular training and supervision. This meant they had up to date skills to be able to support the people who lived there.