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Inspection Summary

Overall summary & rating


Updated 24 December 2016

The Limes 2 is located in a residential area of Brierfield, near to the town centres of Burnley and Nelson. The purpose of the service is to provide accommodation and personal care for up to seven people who have a mental disorder. There are some amenities close by, such as shops and pubs. . Public transport links are nearby and on road parking is permitted.

The last inspection of this location was conducted on 08 January 2014, when all five outcome areas assessed at that time were being met. This inspection was conducted on 04 October 2016 and it was unannounced, which meant that people did not know we were going to visit the home.

A registered manager was in post at the time of our inspection. 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 of the Health and Social Care Act and associated regulations about how the service is run. The deputy manager was in charge of the home on the day of our inspection. However, the registered manager attended the inspection later in the day.

The care planning system was person centred providing clear guidance for staff about people's needs and how these needs were to be best met. The plans of care had been reviewed periodically.

Risks to the health, safety and wellbeing of people who used the service had been appropriately assessed and managed effectively. Where risks were identified these were addressed through robust care planning.

Fire procedures were easily available, so that people were aware of action they needed to take in the event of a fire and records we saw provided good information about how people needed to be assisted from the building, should the need arise.

A range of internal checks were regularly conducted and environmental risk assessments were in place, showing that actions taken to protect people from harm had been recorded.

Records showed that equipment and systems within the home had been serviced in accordance with the manufacturer’s recommendations. This helped to protect people from harm. Evidence was available to demonstrate that good infection control protocols were being followed in day-to-day practice.

Records showed that Mental Capacity Assessments had been conducted, in order to determine capacity levels.

The rights of people were protected as the service worked in accordance with the Mental Capacity Act and associated legislation. People's privacy and dignity was consistently respected.

The service had reported any safeguarding concerns to the relevant authorities and suitable arrangements were in place to ensure that sufficient staff were deployed, who had the necessary skills and knowledge to meet people's needs safely. A range of training for staff was provided. However, some areas of learning could have been completed by a higher percentage of the staff team. We have made a recommendation about this.

Recruitment practices adopted by the agency were robust. Appropriate background checks had been conducted, which meant that the safety and well-being of those who used the service was adequately protected.

There were effective systems in place for monitoring the safety and quality of the service. Audits viewed had identified any areas which were in need of improvement and action was taken to address these shortfalls.

Complaints were managed well and people we spoke with were aware of how to raise concerns, should they need to do so. Systems were in place to ensure that any complaints received were responded to in a timely manner and a thorough investigation was conducted.

During the course of our inspection we assessed the management of medications. We found that, in general these were satisfactory. However, we made recommendations in relation to recording of staff competencies, PRN [as and when required] protocols and the processes for the dispensing of medications. The service worked well with a range of community professionals. This helped to ensure that people's health care needs were being appropriately met.

People we spoke with were highly complementary about the staff team. They felt that they were treated in a kind, caring and respectful manner. People expressed their satisfaction about the home and the activities, which they were supported to enjoy.

Regular meetings were held for those who used the service. This enabled people to discuss topics of interest in an open forum and people's views were also gained through processes, such as satisfaction surveys.

We did not find any breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Inspection areas



Updated 24 December 2016

This service was safe.

There were sufficient numbers of staff on duty and recruitment practices adopted by the home helped to ensure that only suitable staff were appointed to work with this vulnerable client group.

Medications were, in general satisfactory and risks to people's health, safety and well-being were appropriately addressed to ensure that those who stayed at the home were protected from harm.

Safeguarding referrals had been made to the relevant authorities and emergency plans had been generated, so that people were kept safe. Staff members were aware of the procedures to follow should they have concerns about the welfare of those who stayed at the home. Accident and incident records were maintained appropriately.



Updated 24 December 2016

This service was effective.

Records showed that staff received a good induction programme when they started to work at the home. This was followed by a range of training for moist staff members, regular supervision and annual appraisals.

We noted that the principals of the Mental Capacity Act were being followed in order to keep people safe. People who used the service had given their consent to the care and support received, but if they lacked the capacity to do so then someone who had the authority to give consent did so on their behalf.

The premises were well maintained and suitably adapted for those who lived at the home.

People received a well-balanced nutritious diet and they were able to choose what they wanted to eat.



Updated 24 December 2016

This service was caring.

Staff were seen to be kind, caring and respectful of people's needs.

Those who lived at The Limes 2 were supported to be involved in the day to day activities of the home and were enabled to access advocacy services, should they require this.

Records were retained in a confidential manner and people's privacy and dignity was consistently respected.

Those who stayed at the home were supported to maintain their independence, as far as possible and staff members communicated well with those in their care.



Updated 24 December 2016

This service was responsive.

The plans of care were based on assessments of people's needs and we found them to be up to date, person centred and well written documents, providing the staff team with clear guidance about people's needs and how these needs were to be best met.

Those who stayed at the home were supported to undertake activities of their choice, in accordance with their interests and preferences. Staff supported people to maintain their individuality and to participate in activities specific to them.

Complaints were being well-managed and clear systems were in place for the recording of complaints, so that these could be appropriately monitored and any themes identified at an early stage.



Updated 24 December 2016

This service was well-led.

The home had developed some good systems for assessing and monitoring the quality of service provided. These included audits and surveys for service users and their relatives.

A wide range of policies and procedures were in place, which provided the staff team with relevant guidance and current legislation in a variety of areas.

Meetings were also held for the staff team, so that important information could be appropriately disseminated and so that those who worked at the home could discuss any relevant topics in an open forum.