Limetrees

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. 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 the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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. They did not always understand the challenges and the needs of people and their communities.

There were inconsistencies in shared direction and culture across the service, with some staff feedback indicating a lack of consistency in leadership approaches and communication. Staff described variations in expectations and messaging, which at times impacted how care was delivered and understood across the team. There were also indications staff did not always feel fully supported or recognised, which had an impact on morale.

We did find evidence of positive elements of the culture of the home. Staff were observed to be caring, supportive of one another, and committed to people, contributing to a warm and friendly environment. Relatives we spoke with also described the atmosphere positively. One relative told us, “The atmosphere of the home is friendly.”

Leaders were open to feedback and responsive during the inspection, demonstrating a willingness to improve and take action where concerns were identified. They showed a commitment to developing the service and supporting staff to deliver good care.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

Leaders were not consistently demonstrating a clear and inclusive approach, with some staff feedback indicating variability in leadership style, communication, and support. Staff described inconsistencies in expectations and a lack of recognition at times, which impacted morale and the overall working environment.

Leaders were visible within the service and approachable, with relatives confirming they could raise concerns easily. One relative told us, “The management team are easy to talk to,” others described them as supportive and accessible.

Leaders were also responsive during the inspection, engaging openly with feedback and taking steps to address identified concerns. This demonstrated a willingness to improve and a commitment to developing the service.

People did not always feel they could speak up and that their voice would be heard.

There were some inconsistencies in how confident staff felt to speak up, with feedback indicating not all staff felt fully supported or listened to when raising concerns.

Some staff described challenges around communication and felt feedback was not always recognised or acted upon, which may impact openness within the culture.

People and relatives felt able to raise concerns. Relatives we spoke with told us they were confident in approaching management. One relative told us, “I can raise anything,” and others describing the management team as approachable and accessible.

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.

We saw evidence staff were working in inclusive ways and treating people with equality, dignity, and respect, contributing to a positive and welcoming culture within the home. Staff were observed interacting warmly with people, taking time to listen, support, and adapt their approach based on individual needs. For example, staff were seen offering reassurance, adjusting communication styles, and supporting people at their own pace, helping ensure individuals felt comfortable and included.

People living at the home were supported to access communal spaces, activities, and social opportunities, promoting inclusion and reducing isolation. The service also encouraged community links, with visitors and volunteers engaging with people, supporting an open and inclusive environment.

Staff demonstrated respect for people’s individual preferences and routines, supporting choice in daily living and maintaining a sense of identity and independence. Interactions were generally kind and respectful, indicating an understanding of the importance of equality in how care was delivered.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found improvements were needed within the provider’s governance and management arrangements. These include inconsistencies in the application of policies, limited use of performance data to inform decision-making, and gaps in communication across different levels of the organisation. In addition, sustainability practices were not yet fully embedded, with environmental initiatives and long-term planning lacking clear measurable targets in some areas.

Audits were not always being completed in line with the provider’s policies. For example, the provider’s policy stated medication audits were to be completed weekly on controlled drugs. This was not being completed at this frequency and we identified inconsistent completion of these audits over a 3-month period.

The provider did have an established governance framework with defined roles, responsibilities, and oversight structures in place. Management demonstrated a commitment to delivering operational objectives, supported by performance monitoring processes and staff supervision. There was also a clear intention to improve sustainability, with emerging efforts to address environmental impact, promote staff wellbeing, and ensure financial stability.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider demonstrated a clear commitment to working collaboratively with partners and engaging with communities. The provider had established strong relationships with healthcare professionals, with effective information sharing and joint problem-solving. These partnerships contributed to improved outcomes and a more integrated approach to people’s care.

We saw engagement with communities was recognised as an important priority. Efforts to involve communities and gather feedback helped to build trust and ensured the service remained responsive and relevant.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider demonstrated a strong commitment to learning, continuous improvement, and innovation. There was clear recognition of the importance of reflecting on performance, identifying areas for development, and implementing changes to enhance care delivery. Processes were in place to review outcomes, learn from experience, and share good practice across teams.

Staff were encouraged to develop their skills and knowledge through training, supervision, and professional development opportunities. This supported a culture where individuals felt empowered to contribute to improvements and adapt to changing demands. Learning was reinforced through regular feedback.

The provider was open to innovation, seeking new and more effective ways of working. This included adapting processes, embracing new approaches, and collaborating with partners to improve outcomes. There was evidence of a proactive mindset towards change, with a willingness to test and implement improvements where needed.