Limefield Court Retirement Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance and record keeping.

This service scored 61 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider had systems to providing some oversight of the service. Information had not been used to inform a development plan setting out planned improvements to enhance people’s care and experience, including changes to the environment to better meet people’s needs and opportunities for better engagement and inclusion.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Managers had clearly defined delegated roles and responsibilities. We were informed by the local authority, managers had been responsive to support offered in areas for improvement. They were also taking part in areas of training to improve their knowledge and understanding in specific areas of responsibility.

Staff spoken with said they were able to speak with the registered manager in confidence and felt supported. People and their relatives also spoke positively about the management of the service. We were told, “[Registered manager] is very nice, very kind” and "The manager is approachable yes."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Systems were in place to support staff in raising concerns or suggesting improvements. Staff spoken with were aware of the whistleblowing procedure and knew who they could speak with in confidence. Staff told us they felt able to approach the registered manager, adding, “I trust her, good leadership” and “Reassuring and keeps confidence.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

All the staff we spoke with felt supported in their role. Staff had access to a staff handbook which outline relevant information in relation to the employment and role and responsibilities.

The provider holds a sponsorship licence, enabling them to employ overseas workers at the 2 care homes owned by Lily Care Limited. Sponsored staff working at Limefield Court confirmed their working arrangements were consistent with the terms and conditions outlined in their Certificates of Sponsorship.

The provider did not always have clear systems of accountability or good governance. They did not always proactively act on information about risk, performance and outcomes.

At our last inspection we identified governance systems had improved however needed embedding to demonstrate effective management and oversight of the service helping to inform and drive improvement. At this assessment we reviewed the systems in place. Records showed managers monitored and reviewed the service through audits and checks. Records reviewed consisted of tick-boxes, confirming what areas had been checked, however lacked any meaningful analysis of findings, trends, or areas requiring improvement. As a result, opportunities to identify and address areas for improvement were missed. Robust evaluation of audit outcomes would enable the provider and management team to develop and maintain a comprehensive service improvement plan, demonstrating how information and feedback is used to drive continuous improvement and enhance peoples experience. This would also support a more proactive, rather than reactive approach, reducing reliance on external reviews to highlight concerns.

Opportunities were available for people, their relatives and staff to share their views. Survey results from July 2026 identified activities and food choices as the areas receiving the lowest satisfaction ratings. The registered manager had acknowledged the feedback and outlined actions being taken in response. However, we found at this assessment further progress was still needed in these areas, as reflected in this report.

Accurate and complete records were not always maintained. For example, staff rotas and recruitment records did not consistently include full names and dates and policies and guidance documents had not been updated to reflect current legislation and best practice guidance.

Notifiable incidents and events were reported to the local authority and CQC when required.

The provider was not always working in partnership, so services worked seamlessly for people. The registered manager had been guided by the local authority quality officer in developing networks with other agencies and care providers, to support their learning.

The registered manager worked in partnership with external organisations, including the local authority and health professionals. Healthcare professionals involved in people’s care was recorded in their care records. The local authority quality officer had supported managers in developing networks with other agencies and care providers, to assist in their learning.

Opportunities to develop relationships with community groups, could be enhanced promoting other activities and opportunities as well as social inclusion.

The provider explored areas for learning but needed to further develop their knowledge and skills to encourage more creative approaches to care and improve people’s quality of life.

Guided by the local authority, managers had recently attended learning events relevant to their role, helping to update their knowledge in areas of current and best practice. The deputy manager was also due to undertake a management and leadership qualification to further develop their knowledge and skills. This would support their understanding of current best practice and leadership approaches within health and social care settings.

Records showed staff team meetings and learning sets were held. However, information did not include evidence of any meaningful discussion to demonstrate staff understanding and learning.