Limefield Court Retirement Home

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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the environment.

This service scored 59 (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 listened to concerns about safety and investigated and reported events, where necessary. Records did not show how lessons were learnt and embedded into practice.

Records showed that regular meetings and learning sessions had taken place. However, documentation primarily listed agenda topics and did not consistently record discussions, learning outcomes, actions taken, or any additional support and development needs identified for staff.

The provider had implemented a clear post-falls protocol, setting out the actions staff should take following an incident. Records showed that 24-hour post-fall observations were completed and documented where required.

The provider maintained an overview of incidents between April 2024 and July 2026, including a description of the incident, actions taken, and outcomes. Eighteen incidents had been recorded during this period. Records indicated that incidents were appropriately monitored, required minimal intervention, and were managed in line with the provider's post-falls protocol where applicable.

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.

People had hospital passports containing key information to support continuity of care when they were admitted to hospital. These included details of their current needs, prescribed medicines, and relevant advance care planning information, including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions where applicable. This helped to ensure important information was available to healthcare professionals, supporting safe and person-centred care during hospital admissions.

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.

People living at the home told us they felt safe and were looked after by staff. People told us, “I feel safe here. They are great the staff, they look after us” and “At the moment I would say there aren’t enough staff but I do feel safe here overall." One relative also commented, “I have no worries about the staff or her safety here."

Policies and procedures were in place to guide staff in safeguarding, whistleblowing and deprivation of liberty safeguards. This was supported by a programme of training. Staff spoken with had a good understanding of the procedures and who they could speak with if they had any concerns.

Where people were deprived of their liberty, lawful authorisations were in place. The management team were aware of the recent Supreme Court judgment making changes in how a deprivation of liberty will now be assessed. Additional training had been attended to assist in their understanding.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Areas of risk were assessed and planned for in relation to falls, weight loss and health care needs, such as diabetes. However, we found assessments and plans needed to be expanded upon providing clear guidance for staff in the management of such risks, ensuring people’s needs were safely and effectively met.

We were told and observed, many people chose to spend time in their bedrooms. People had access to call bells and, where needed, motion sensor mats to alert staff when they required support. Records showed that internal checks of the call bell system were carried out as well as bi-monthly servicing. However, some people told us they may not always receive a prompt response, which could affect their support.

Relevant health and safety checks were in place to ensure the safety and suitability of mains circuits and equipment, such mains electric, gas safety, fire alarm and equipment and moving and handling equipment.

Records showed the testing of small appliances was carried out by the provider. However, information showed relevant training had not been updated since 2019 and the calibration of equipment had not been maintained in line with good practice guidance. This meant the provider could not demonstrate they remained up to date or that equipment was being checked regularly. Following feedback, the provider took action to address these shortfalls.

Servicing of the passenger lift had also been carried out in August 2026. Some areas for improvement were noted. The registered manager was aware of the work required and confirmed this was to be addressed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment would benefit from further improvement to better support people's comfort, independence and wellbeing. We found the décor was dated, woodwork was marked, and communal areas, including the dining and living rooms, would benefit from decluttering. One person told us, "My room is fine, though it could probably do with freshening up a bit." A visitor also told us, “The main issue is the environment.”

Further consideration was also needed to ensure the environment supported those people living with dementia, in line with good practice guidance. Improvements could support people to orientate themselves more easily within the home and maintain their independence.

The fire risk assessment had been completed in October 2024 and identified a review date of October 2025. Not all actions identified within the assessment had been completed including work required to some of the fire doors. Minutes of a senior management meeting held on 22 January 2026 stated that fire doors should not be wedged open. However, during our visits we observed doors being propped open, which was not in line with the fire risk assessment. During the assessment we were informed doorguards had been fitted to several doors. Arrangements should be reviewed along with the fire risk assessment to ensure compliance with regulation.

We reviewed the Personal Emergency Evacuation Plans (PEEP). Information needed to be condensed into one easy to follow plan. We also found the emergency grab bag did not contain key information, including a contingency plan, floor plan and summary of PEEPs. This information is essential to support an effective response in the event of an emergency. Immediate action was taken by the provider to address this.

Records showed fire drills had been completed on 27 November 2025 and 6 June 2026. However, evidence did not demonstrate that all staff, including night staff, had participated in a fire drill. The provider informed us that a further fire drill was to be undertaken to address this.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff were recruited safely, with the necessary pre-employment checks completed, including additional documentation for overseas staff. Recruitment processes could be strengthened by documenting verification of references, recording the interviewer’s name, and retaining scoring and suitability decisions. Records should also provide a clear chronology where there have been changes in employment status or right to work arrangements.

Staff told us they felt supported and confirmed they completed a programme of training including eLearning as well as practical face to face training. Records reviewed confirmed training, supervision and staff meetings were held. While meetings and learning set agendas were available, records did not clearly document discussions, learning outcomes or any actions taken.

People we spoke with felt staff had the skills needed to support them. One person said, “The staff are helpful and they do appear to be well trained in their jobs.”

Staffing arrangements were reviewed. We received mixed feedback from people about staffing levels. Some people felt there were not always enough staff available during busy periods. People told us, “A lot of the staff are very nice. They are helpful and there if you need them. They could maybe do with a few more staff” and “I think there are enough staff. It can be busy at mealtimes and things but they seem to cope?" Staff also told us, “Routines are busy but manageable as the registered manager will help out”.

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.

Systems were in place to manage and minimise the risk of cross infection. Personal protective equipment was readily available throughout the home and easily accessible. Staff were seen using aprons and gloves when carrying out tasks.

The home had been audited by the local authority health protection team in June 2026. The home achieved 97% compliance. The registered manager confirmed action required had been addressed.

A food hygiene inspection had also been undertaken by the Food Standards Agency on behalf of the local authority in June 2026. The home achieved a rating of 5, very good.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People were usually given their medicines safely. Records showed that stock levels were well-managed so that people did not miss their doses, and this demonstrated that medicines were given as prescribed.

However, some areas of medicines management were inconsistent or unsafe, and improvements were needed to make sure people were protected from risk of harm. For example, one person who was prescribed thickeners was given ice cream, which placed them at unnecessary risk of harm. Protocols for medicines prescribed ‘when required’ or with a choice of dose also needed improvement, as they did not always provide enough detail to support safe and consistent administration.

Care plans did not contain enough personalised information to support the safe management of diabetes. The times medicines were given were not always accurate, and some people’s allergies were not recorded. The storage of waste medicines was not in line with current guidance, and the fridge thermometer was not working properly.

We found no evidence that people were harmed at the time of the assessment. However, people were placed at increased risk of harm by not managing medicines safely.

After the inspection information was received which helped mitigate the seriousness of the concerns, but we had no evidence, due to the short timescales, that the improvements were embedded or sustained.