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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 carried out on 9 June 2020

During an inspection to make sure that the improvements required had been made

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 carried out on 10 December 2019

During a routine inspection

About the service

The Limes is a care home providing personal care to 40 people, with a range of support needs. There were 38 people living at the home 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

The service provided to people at The Limes was not consistently safe. People did not always receive their medicines as prescribed. People were not always protected from risks, such as falls. Opportunities to learn from adverse incidents had been missed. The home was not clean and hygienic in all areas; consequently, people were not protected from the risk of infection. There were not always enough staff to ensure people's safety. People were protected from abuse and improper treatment.

People were not supported to have maximum choice and control of their lives and there was limited evidence that staff supported people in the least restrictive way possible and in their best interests; the systems were not effective in preventing this practice. Staff did not have training in some key areas. The management team had identified this and had arranged training. Overall staff told us they felt supported; however, some staff had not received formal supervision. There was a risk people may not receive the support they needed in relation to their health. Overall, we found that people had enough to eat and drink. The home was adapted to meet people’s needs.

People were supported by staff who were kind and caring, staff knew people well and people were involved in making decisions about their care. People were treated with dignity and respect and their right to privacy was upheld.

People did not always receive personalised care that met their needs. Some further work was needed to ensure people were provided with consistent, caring and compassionate support at the end of their lives. People had opportunities to get involved in meaningful activities within the home and in the community and their diverse needs were met. There were systems in place to respond to complaints and concerns.

Systems to ensure the safety and quality of the service were not fully effective, this posed a risk to people’s health and wellbeing. Sensitive personal information was not stored securely and records of care and support were not consistently accurate or up to date. The management team had a vision to provide high quality care, however further work was needed to implement and sustain this. The management team told us action would be taken to address the issues found during our inspection. People, families and staff were involved in the running of the home and there were links with partner agencies and the local community. The management team were meeting their legal duties to notify us about significant events and to display their rating.

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

Rating at last inspection

The last rating for this service was good (published 8 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified breaches in relation to safe care and treatment, consent and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 2 May 2017

During a routine inspection

We carried out an unannounced inspection on 2 May 2017.

The Limes is a residential care home that provides care for up to 40 older people who live with dementia, physical disability and mental health. Accommodation is on two floors connected by a lift. There are communal lounges on both floors and a dining room on the ground floor. People using the service have access to a garden. At the time of our inspection 37 people were using the service.

At our last inspection in October 2014, the service was rated ‘Good’. At this inspection we found that the service remained ‘Good’ for being safe, effective, caring, responsive and well-led.

People continued to receive safe care. All staff, including care workers and domestic staff knew how to recognise and report any signs that people were abused or at risk of abuse.

The provider had assessed risks relating to people’s care to help them to remain safe whilst encouraging them to be as independent as they wanted to be. The provider had procedures in place for staff to report concerns and for those concerns to be investigated and acted upon.

Staff were appropriately recruited and there were enough staff to provide care and support to people to meet their needs. People were supported to receive their medicines safely.

The care that people received continued to be effective. Staff had access to the support, supervision and training that they required to work effectively in their roles. People were supported with their nutritional and health needs and were supported to access health services when they needed to.

People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

People developed positive relationships with the staff that were caring and treated them with respect, kindness and dignity.

People had care plans in place that were focused on them as individuals. This allowed staff to provide consistent support in line with people’s personal preferences.

People’s needs were met in line with their individual care plans and assessed needs. Staff understood people’s needs and provided care and support that was tailored to their needs. This included providing people with stimulating and meaningful activities.

People and their relatives felt they could raise a concern and the provider had systems to manage any complaints that they may receive.

The provider had effective arrangements for monitoring and assessing the quality of care people experienced. These included seeking and acting upon the views for people who used the service, their relatives, staff and health professionals who visited the service.

Further information is in the detailed finding below.

Inspection carried out on 2 October 2014

During a routine inspection

This inspection took place on 2 October 2014 and was unannounced.

The Limes is a residential care home which specialises in caring for adults with dementia, learning disabilities, mental health conditions, physical disabilities and sensory impairments. The service is registered to accommodate up to 40 people. Thirty nine people used the service at the time of our inspection.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People who used the service told us they felt safe. People were protected from harm and abuse because the provider had safeguarding procedures that staff understood and used. Staff knew how to identify and report any concerns they had about people’s safety. People’s plans of care contained risk assessments of activities associated with people’s care which reduced the risk of them experiencing harm.

Enough suitably trained staff were on duty to meet the needs of people using the service. The provider had robust recruitment procedures that ensured as far as possible that only people suited to work at the service were employed.

People were supported to receive their medications at the right time. The service had safe arrangements for the management of medicines.

People were cared for and supported by staff who had received relevant training that enabled them to understand and meet their needs. Staff understood how the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) applied to people who used the service. MCA and DoLS set out the requirements for ensuring that decisions are made in people’s best interests when they are unable to do this for themselves.

People were supported to have sufficient to eat and drink throughout the day and people’s dietary needs were met and their food preferences respected. People were supported to maintain their health. The service had arranged for regular visits by a doctor, district nurses and other health professionals to attend to people’s health needs.

Staff treated people with dignity and respect. Staff had developed caring relationships with the people they supported. The service involved people and their relatives in decisions about their care and support. People had access to independent advocacy services if they needed them.

People’s plans of care contained information about their individual needs. Staff referred to plans of care and provided care in line with those plans. People were encouraged to share their experience of the service with staff and knew how to raise any concerns. People’s views had been acted upon.

The registered manager had a clear vision about what they wanted the service to achieve. That vision was understood and supported by staff. People using the service, their relatives and staff were involved in developing the service.

The registered manager understood their responsibilities and demonstrated a commitment to continually improve the service The registered manager was supported by senior managers. There was an effective procedure of analysing and monitoring the quality of the service.

Inspection carried out on 4 September 2013

During an inspection to make sure that the improvements required had been made

We spoke with six people who used the service, five members of staff, one visitor to the service and one visiting health professional. We also reviewed six care records.

We spoke to a visiting health professional and asked them their views on the quality of care. Their response indicated they felt the care given was of a high quality. They told us: �The care given to the person I am visiting is positive and refreshing. They have blossomed since coming here�.

We spoke with the manager who explained that the provider had recently inspected the premises and had initiated a refurbishment plan. We noted that this work was in progress and several carpets and some flooring had been fitted in the last few weeks and the outside area was to be modernised in the near future.

We spoke with a number of staff and asked them if equipment was easily accessible and in good working order. Their responses indicated that there was enough equipment for them to fulfil their duties and meet the needs of the people who used the service.

We asked the staff we spoke with to describe to us how supported they felt. Their responses indicated that since the appointment of the new manager they were very well supported. One member of staff told us: �We previously had very little support. We have already had a meeting with the new manager, which was very reassuring. The future is much brighter now."

Inspection carried out on 18 June 2013

During a routine inspection

We spoke with seven people who used the service, one visitor to the home, two visiting health professionals and eight members of staff. We also reviewed five care records.

We observed good interaction between staff and the people using the service and saw choices being given to people and verbal agreement gained before carrying out care.

Staff demonstrated they understood the concept of ensuring care plans were current and care needs accurately recorded in the care records. However we were unable to corroborate this was happening in practice as the care records reviewed did not demonstrate a consistent approach to the documentation and monitoring of care need assessments.

We observed a member of staff carrying out the medication round. They were observed administering medication discreetly and at a pace that suited the individual.

We randomly selected three days within the month of June 2013 and confirmed that the number of staff on all shifts matched the staffing level standard. One member of staff we spoke with told us that the use of agency staff had dramatically diminished over the last few months.

A member of staff explained to us a two hourly walk round of the premises was conducted by a senior member of staff. The walk round consisted of observational checks on personal care, staff interaction, activities, general atmosphere and the environment.