The Limes Care 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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations related to safeguarding and safe care. Safeguarding concerns were not always identified and reported. Incidents were not always well documented or managed. Care plans did not always contain enough information on managing risks. Medicines were not always managed safely. Environmental safety and infection prevention and control risks had not always been managed.
 

This service scored 31 (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. They did not always listen to concerns about safety and did not investigate or report safety events. Staff had not always appropriately recorded incidents, such as when people experienced emotional distress or when staff had used restrictive practices such as delivering care when people had refused with restraint or physical intervention. This meant the provider could not investigate and report all safety events. This placed people at increased risk of harm.

The service did not always maintain safe systems of care to manage risks that people could experience or be exposed to. Safeguarding concerns were not always identified, health risks to people were not always well managed, and care plans did not always reflect people’s needs. For example, one person’s care plan stated that they needed an action plan for health condition but this was not in place.

However, a relative told us, “[Relative ] has only recently moved there but they have been brilliant.”
 

People were not always protected from abuse and improper treatment. The provider had failed to identify and report all safeguarding concerns to the Local Authority safeguarding team. Failing to recognise potential safeguarding concerns placed people at increased risk of harm.

Although some relatives told us about particular incidents where they had concerns, the majority of people and their relatives told us they felt safe. A person told us, “I feel safe with carers.” A relative said, “On the whole I think [relative] is safe although there have been a few issues.”
 

The provider did not always work well with people to understand and manage risks. For example, where people were known to experience emotional distress, to the extent that staff used restrictive practice, care plans and risk assessments did not contain enough information about how to support them. Risks related to people's mobility were not always accurately reflected in people's care plans. For example, we found that a person's care plan stated they did not use bedrails when, in fact, they did. However, care plans did contain information such as highlighting risks relating to high/low blood sugar for people living with diabetes and risks pertaining to flammable topical medicines. A relative told us, “They try very hard to keep [relative] mobile and support [relative] to use [their] frame.”

The provider failed to detect and manage all potential risks in the care environment. There were increased fire-related risks. For example, we observed fire doors to be wedged open, a person's bedroom not being suitable for use due to fire regulations and a person smoking in their bedroom, which was cluttered with potential fuel sources. Hot water and surface risks were also not mitigated. We identified outlets and surfaces in bedrooms that could get hot enough to scald or burn people. Risks of falls from height were not mitigated, we identified 3 windows lacking restrictors and tamperproof fittings not being installed. Oxygen signage was also absent from a person’s bedroom. Although the provider took or planned actions in relation to our concerns, they had failed to identify this independently before our inspection.

However, other required checks such as those relating to lifting equipment and gas safety had been completed. A person told us, “What I like is that it's a small care home and it suits me. I would never be happy in a big, modern place.”
 

The provider did not make sure staff were always trained or competent. Safeguarding concerns were not always identified and reported, despite staff having received training in safeguarding. We observed that people were not always supported to mobilise safely, and fire risks were not being well managed, despite staff having received training in this area and the service having its own in-house trainers. Where records showed staff had only completed online first aid training, there was no assessment of their practical skills and competence in this. At the time of our inspection, staff had not received training in supporting people with prescribed oxygen and diabetes. Staff were not always recruited safely, as we found the provider had not documented why staff had gaps in their employment history. This increased risks relating to the provider not doing all that was practicable to ensure candidates were of good character prior to employment.

However, we did not find any concerns in relation to the number of staff deployed, a relative said, “There seems to be a good number of carers.” A person said, “I have all the help I want.”

We observed during our first 2 visits that the external general waste bins were overflowing, and the area had an offensive odour. In the kitchen, we observed that the freezers needed defrosting. We observed a communal bathroom would benefit from a deeper clean due to sealant being visibly unclean. We observed the communal microwave was dirty. These concerns increased infection prevention and control risks.

However, other communal areas and people's bedrooms were generally clean and free from malodour. We observed that staff had access to enough PPE.
 

The service did not make sure that medicines and treatments were safe. We identified concerns with the safe storage of topical medicines due to the presence of expired or undated medicines. Protocols for medicines used on an ‘as required’ (PRN) basis were not always in place or did not contain correct information. We observed that a staff member kept spoons in their tabard when administering medicines, alongside their keys, and could not tell us when the tabard had last been washed. We found a person's electronic medicines record and their care plan did not have complete information about all of their allergies. This put people at risk as they were not always being supported safely with their medicines.