Limetrees

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. This is the first assessment for this newly registered service that registered with us in 2023. This key question has been rated 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.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider’s learning culture was not consistently effective, with evidence learning from incidents, audits, and feedback was not always embedded into practice. Although systems such as audits and checks were in place, these had not consistently identified or addressed ongoing concerns. For example, concerns were identified in medication management, environmental risks, and care records, indicating previous learning had not been effectively sustained.

Actions identified were not always carried through into practice, resulting in continued inconsistencies. For example, actions regarding fire concerns had not been acted on or acknowledged on the fire risk assessment. This demonstrated learning was not always shared and embedded across the home.

Learning appeared at times to be reactive rather than proactive. Restrictions were imposed on all people following 1 isolated incident regarding 1 person. We saw evidence leaders were beginning to recognise and respond to concerns found in the home. One leader told us, “We’re finding more gaps now than we used to in medication, conducting the quality checks are helping us see where things are going wrong.” Leaders were open to our feedback and took action during the assessment to begin addressing concerns.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems to support safe care were not consistently reliable, with gaps in records, monitoring, and follow-through creating risks to continuity of care. We found missing signatures, incomplete checks, and unclear accountability, meaning it was not always evident who had completed tasks or whether actions had been taken.

Care planning and assessing processes were not always aligned, with inconsistencies in mental capacity and DoLS documentation. Monitoring records, such as fluid charts, did not always show clear action when concerns were identified, meaning changes in people’s needs were not always effectively responded to.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Safeguarding systems were not consistently embedded in practice, with some gaps identified in how risks were managed and monitored. While there was no direct evidence of harm, inconsistencies in areas such as risk management, environmental safety, and record keeping meant potential safeguarding risks were not always proactively identified or reduced.

For example, we observed situations where risks were not consistently managed, including equipment not being used as intended, items left accessible in communal areas, and a lack of clear rationale for some restrictions in place. For example, 1 person had their bed pushed up against a wall, causing a restriction, as no DoLS or authorisation was in place to support this action. Records did not always demonstrate concerns, such as changes in behaviour or health risks, were clearly escalated or followed up.

Staff interactions were mostly kind and respectful. People and relatives expressed confidence in the care provided. One person told us, “I know we can trust you to keep us safe,” and a relative shared, “The care staff are very attentive, caring, and kind.”.

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.

People were not always involved in decisions about managing their risks, and records did not always reflect how individuals participated in these discussions. Care plans and risk assessments were sometimes unclear or incomplete, with limited evidence people’s views, preferences, or consent had been fully considered or documented.

We found examples where restrictions or safety measures were in place without clear rationale or evidence of least restrictive practice, including inconsistencies in the use of equipment such as sensor mats and monitoring approaches. In addition, inconsistencies in mental capacity assessments meant it was not always clear whether people were being appropriately supported to make their own decisions.

Some people reported feeling involved and supported. One relative told us, “We spent two or three hours developing her care plan,” One person told us, “They are very careful about your dignity and ask in such a lovely way.”

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 was not always managed to ensure people’s safety. We observed fire doors being obstructed and not closing properly, and outstanding fire safety actions had not been completed in a timely manner. This placed people at potential risk in the event of an emergency.

We found environmental concerns included items being left accessible, such as razors and creams in bedrooms and communal areas, some of which were open, undated, or out of date. This was high risk due to items being found in the dementia area where people were known to walk around the home. We were unable to locate equipment used to monitor safe water temperatures, despite being informed these were in place.

Equipment used to reduce risk was not always used effectively. For example, staff were not always clear on the purpose or positioning of sensor alarms, reducing their effectiveness in supporting people safely.

However, people and relatives mostly described the home positively. One relative said, “It is a lovely place, the staff are very supportive,” and another shared, “[Person] is very comfortable in her room at all times.”

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.

Staffing was not always safe and effective, with evidence staffing levels, skill mix, and deployment impacted the quality and timeliness of care. Relatives generally felt staffing levels were sufficient, observations showed occasions where people experienced delays in support and inconsistencies in care delivered.

One person told us, “I waited nearly an hour, there was no-one around to help me,” which highlighted staff deployment around the home was not always in support of people’s needs. During our on-site visit, we observed there were instances where staff did not promptly respond to situations, such as interactions between residents or support needs during mealtimes.

The service had vacancies and required the use of agency staff. While some relatives felt this did not impact care, others felt and our observations indicated some differences in consistency and approach. One resident commented, “Agency staff stick out, there’s no personal touch.”

We found gaps in the completion of key tasks, such as daily checks, cleaning schedules, and monitoring records, particularly during night shifts. This indicated staffing deployment and management oversight were not always effective in ensuring required tasks were completed.

People’s overall feedback was positive about staff attitudes. Relatives said, “The care staff are very attentive, caring, and kind,” and “Most of the time, there are sufficient care staff available to help.”

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.

We found some processes were not consistently embedded or effectively managed, with gaps identified in cleaning schedules, equipment management, and environmental oversight. Records we reviewed showed cleaning tasks, particularly on night shifts, were not always completed, and there was a reliance on agency staff, which impacted consistency. We raised this with the registered manager and operations manager. Leaders provided evidence to show they were working to employ staff and were monitoring and responding to the gaps in records found.

People and relatives did not raise concerns about cleanliness, with one relative stating, “It is a lovely place, [Person] is very comfortable in her room,” The environment on both of our on-site visits was clean, organised and looked after.

Staff were aware of infection control and the importance of maintaining good standards of hygiene and cleanliness. Staff had completed infection control training.

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.

Medicines management was not consistently safe or well managed, with gaps identified in recording, administration, and oversight. We found missing signatures on MAR charts, no appropriate codes recorded for omitted medicines, and occasions where medicines could not be clearly tracked. For example, one medicine was not signed for, which meant it was unclear whether it had been administered or not.

Controlled drug records were not consistently completed, with missing second signatures identified on more than one occasion. Medication audits were in place but were inconsistent and not completed at the required frequency, limiting effective oversight and identifying concerns early.

We found concerns on how medicines were administered but not retrospectively signed or recorded correctly. This increased risks of unsafe medicines administration.

However, some positive systems were in place, including clear processes for self-administration and competency checks for staff. Leaders had identified concerns and were taking steps to improve oversight. People and relatives were confident with how medicines were administered, one person told us, “I have no worries at all that [Person] is receiving their tablets properly.”