Updated 12 June 2025
This inspection took place on 17 September 2025, 2 October 2025 and 8 October 2025 and was unannounced. The service is a residential care home providing support to adults of all ages living with dementia, nursing needs, mental health conditions and physical disabilities. Limewood Nursing and Residential Home accommodates up to 65 people over 7 'clusters'. At the time of the inspection, the service supported 57 people.
This inspection was prompted by concerns about care and treatment, including unexplained injuries, poor management oversight, gaps in staff training, outdated care plans, poor continence care, staffing shortages, and inconsistent management of people’s distressed behaviours. While we did not find evidence to substantiate all these concerns, we did identify inconsistent management of distressed behaviours and other separate issues.
Infection prevention and control was not managed effectively. Failures in communication and oversight led to unclear processes for managing suspected infections, and the provider could not give assurances that risks were controlled. This resulted in a breach of regulation in the safe care and treatment of infections. The provider took immediate action including compiling an action plan and completing a root cause analysis to prevent recurrence.
Governance arrangements were not fully effective, as leadership lacked oversight of infection prevention and control, which had contributed to the breach of regulation, although audits and checks were in place. A new IT system was being introduced to improve efficiency and oversight. Following feedback, additional actions were implemented to strengthen monitoring and assurance.
People did not have access to call bells to summon help and support. Following feedback, handheld and pendant call bells were introduced to improve accessibility and independence.
There was no evidence available that maintenance staff completed routine water temperature checks, although care staff checked temperatures during tasks.
People were treated with kindness, compassion and respect. Care and support were person-centred and tailored to meet individual needs, with staff promoting privacy, dignity, and a sense of safety.
People were supported to maintain their health and wellbeing, with care plans reviewed regularly to ensure they remained effective and responsive to changing needs.
Support was provided in the least restrictive way, in line with legal requirements and in the best interests of each person.
Medicines were managed safely and in accordance with policy, with secure storage and accurate records maintained. Safeguarding systems were in place, and staff understood their responsibilities, acting appropriately when concerns were raised. There were enough safely recruited and suitably skilled staff to meet people’s needs. Staff worked in partnership with health and social care professionals to help people achieve positive outcomes. Staff demonstrated a clear understanding of people’s rights and how to uphold them in day-to-day practice. They felt well supported and valued by the provider, with access to regular supervision and training.
There was an open and inclusive culture where staff felt confident to raise concerns.
Audits and checks were carried out regularly, and new IT systems were being introduced to ensure any issues were identified and addressed promptly in a more efficient way.
There were lots of activities taking place in the high street on the ground floor, however, some relatives said there could be more activities within the clusters, which the registered manager agreed to address. The environment was clean and tidy, and rooms were personalised.
We observed staff engaging respectfully and involving people in some activities.