Limewood Nursing and Residential 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

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. 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 62 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team were committed to providing a person-centred and inclusive environment. People and their relatives were actively encouraged to participate in the development of the service through residents’ meetings and other engagement opportunities.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

People, staff and relatives were complimentary about the leadership team within the service. We were told the leadership team was approachable, supportive, responsive and visible in their day-to-day interactions. A person told us, “I have met the manager—they are very approachable.” A relative told us, “I know who the [registered manager] is they are very kind; they are very busy but would find time for you.” A relative told us the [registered manager] regularly walked the home and has an open-door policy.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

One relative told us, “Staff are warm and welcoming and make time to talk to you and are very approachable.”

Staff reported feeling comfortable and confident they would be listened to. One staff member told us, “The [registered manager] was approachable, supportive, and operated an open-door policy.”

Clear whistleblowing procedures, aligned with national guidance, were available to residents, relatives, and staff.

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.

The staff team came from a range of diverse backgrounds, and all those we spoke with said they felt comfortable and welcomed within the service. No concerns were raised regarding equality or diversity.

The provider did not demonstrate effective governance or management systems to ensure safe and sustainable care. Leadership failed to maintain oversight of critical safety processes, including infection prevention and control.

Communication between staff and management was inconsistent, which could have contributed to delays in addressing safety concerns. These gaps showed that governance arrangements were not sufficiently embedded to prevent avoidable harm or ensure compliance with regulatory requirements.

Governance arrangements were not robust enough to manage infection risks effectively. Quality monitoring systems were in place but not consistently applied to infection control. Audits failed to identify gaps in communication and PPE use, so risks were not escalated promptly. Leadership lacked clear oversight of outbreak management, making governance reactive rather than preventative. The provider’s governance systems could not evidence that regular water testing was taking place to ensure compliance with legionella requirements and to prevent scalding.

Audits of incident reports (ABC charts) were not taking place to ensure lessons were learned, themes were not identified to prevent further incidents and support people safely. These concerns meant the provider was in breach of regulation around the safety of the service. Improvements occurred only after the inspection.

The home was introducing an electronic system for quality assurance and care planning, which was expected to strengthen oversight and improve efficiency further. Following the feedback, the registered manager implemented additional governance measures to strengthen safety systems, including infection prevention and control.

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.

We saw evidence of multiple professionals involved in supporting people’s care. For example, the local GP, physiotherapist, Speech and Language Therapist (SALT), occupational therapist, and social worker all played key roles. This ensured individuals at the service received timely and appropriate support from the right professionals.

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.

A quality assurance framework was in place however following concerns about infection control, and water temperature checks, the provider introduced additional audits for health and safety and infection control. Findings were reviewed and used to implement action plans.

Senior staff supported ongoing learning and improvement. Staff were encouraged to share ideas and work collaboratively to achieve positive change.

Staff told us they felt valued and engaged in the improvement process. Lessons learned were shared openly, creating a culture of reflection.

During feedback, the registered manager responded promptly and proactively to concerns raised to ensure improvements were implemented and risks were reduced.