The Limes Care 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 inadequate, and the service was in breach of the legal regulation in relation to governance. At this assessment the rating has changed to good and the service is no longer in breach of the legal regulations. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a shared focus on improving the service, and staff understood their roles and responsibilities. Staff told us the manager was approachable and visible, and they felt able to raise concerns. Governance systems were developing and beginning to identify issues, which were being addressed through action plans. Staff generally worked together to meet people’s needs, and there was evidence of learning from incidents and reviews.

The management team were visible, approachable and worked alongside staff in the service. Leaders were hands on in day‑to‑day care, setting a positive example and supporting staff to provide good care. Staff said they felt supported and able to talk openly about challenges, and managers offered guidance and reassurance when issues arose. Leaders showed commitment to learning and improvement and were responsive to concerns raised.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident to speak up and raise any concerns they might have. A relative said, “I have complained before and been happy with the outcomes.”

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. Staff told us they felt supported and well treated.

The provider had governance systems and processes in place to support oversight of quality, safety and performance; however, these were not yet consistently embedded across the service. Information relating to risk, performance and outcomes was available, but assurance arrangements were not always used to their full potential to support ongoing learning and improvement. While there was evidence of oversight and monitoring activity, governance processes would benefit from further development to ensure they consistently and effectively support high‑quality, sustainable care for people using the service.

The provider worked with a range of external professionals to support people’s care. Records showed involvement from health professionals such as GPs, dietitians and district nurses, with referrals made when concerns were identified. A visiting health professional told us they had seen significant improvements since the last inspection and highlighted how communication had improved greatly.

The provider had made improvements since the last inspection and had taken action to address many of the issues identified. There were systems in place to help the service learn from incidents and feedback, and we saw examples where changes had been made as a result. This showed a commitment to improving the quality of care. However, these improvements were not yet fully established across the service, and some areas still needed time to develop further to make sure learning consistently led to better experiences and outcomes for people.