You are here

We are carrying out a review of quality at The Limes. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 28 July 2020

About the service

The Limes is a residential care home providing personal care to up to 40 people with a range of support needs. There were 34 people living at the service at the time of our inspection. The service provides support to older people some of whom are living with dementia.

The Limes is purpose built. It is split over two floors with communal areas on each floor.

People's experience of using this service and what we found

People were not protected from the risk of avoidable harm or abuse because the systems and processes in place to safeguard people were not effective. There were a high number of unwitnessed falls and opportunities to learn from accidents and incidents were missed.

There was not a registered manager. The acting manager did not receive sufficient support. There were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high quality care. Quality assurance systems and processes failed to identify concerns relating to safe care. Where issues had been identified the service did not act in a timely manner to address these.

Care plans and risk assessments were not sufficiently detailed or accessible to staff. Areas of the service were dirty and in need of redecoration, refurbishment and maintenance.

Infection prevention and control procedures were not following expected guidance and requirements. Staff did not always wear the protective personal equipment such as face masks when in direct contact with people. They did not always follow effective handwashing or any handwashing between contact with different people. This meant people were put at increased risk especially during the COVID 19 pandemic.

Staffing numbers were not sufficient to meet people’s needs or keep them safe.

There were risks that people would not get their prescribed medicines at the right time. Administration records were not always completed accurately. Medicine trained staff were not available on every shift and some staff had not had their competency to manage people's medicines assessed.

Staff did not have time to spend with people and could not always meet people’s needs or keep them safe. People did not receive the reassurance and support they required when they were distressed because staff did not have time or did not have the skills required to support people living with dementia. People’s privacy and dignity was not always protected.

For more details, please see the full report which is on the CQC website at

Rating at last inspection (and update)

The last rating for this service was requires improvement (Published 24 January 2020) and there were multiple breaches of regulation. The rating for the service has changed from requires improvement to Inadequate. This is based on the findings at this inspection.

We received concerns in relation to the management of the service and peoples care needs. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We also checked whether the Warning Notice we previously served in relation to breaches of regulation had been met. The overall rating for the service has changed following this focused inspection to inadequate.

Why we inspected

The inspection was prompted in part due to concerns received about failure to protect people from avoidable harm or abuse and improper treatment. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, caring, and well-led sections of this full report.

You can see what action we have asked the provider to t

Inspection areas



Updated 28 July 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 24 January 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 28 July 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 24 January 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 28 July 2020

The service was not well-led.

Details are in our well-led findings below.