The Limes Retirement Home

Updated 7 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by one inspector.

Service and service type

The Limes Retirement Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The Limes Retirement Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post. The registered manager is also a director of the organisation.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service, including safeguarding. We used all this information to plan our inspection.

During the inspection

We visited the premises on 14 April 2022, we spoke with the registered manager and four staff including care, training and domestic staff. We also spoke with five people who used the service and two relatives about their experience of the service provided. We observed staff interactions, lunch time and medicines administration. We reviewed a range of records including two staff recruitment records, training records, medicines records, risk assessments and records relating to the management and governance of the service.

On 15 April 2022 we sought feedback from relatives and staff. We reviewed the care plans of four people using the service and a record of actions taken as a result of our last inspection. We also fed back our findings of the inspection to the registered manager.

We received electronic feedback from three relatives and one staff member.

Updated 7 May 2022

About the service

The Limes Retirement Home is a residential care home providing accommodation and personal care for up to 26 people. The service provides support to some people who were living with dementia. At the time of our inspection there were 24 people using the service.

The service provides personal care to people living in one adapted building and two of the bungalows on site. There are other bungalows on site, the service is not permitted, under their registration, to provide any personal care support to the people who live in them

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

The provider had improved the systems to identify risks and guide staff in how to mitigate them to reduce the risks of avoidable harm and abuse. Where an incident had happened, the provider had put systems in place to reduce them happening again.

Staffing levels were being kept under review and recruitment of staff was done safely. Medicines were being managed safely and people received their prescribed medicines. The service was clean and infection control systems reduced risks to people. Government guidance was followed in relation to the COVID-19 pandemic, including supporting people to have visits from family and friends.

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

People’s care plans had improved and further development in this area was ongoing. The care plans included information to guide staff on how people’s needs were being met, including their end of life decisions. People were able to participate in activities to reduce the risks of boredom. There was a complaints procedure in place.

The provider had made improvements since our last inspection which were ongoing. The provider had accepted the support from the local authority to develop the service, including workshops for staff in recording. The service was monitored by the management team to identify and address any shortfalls.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 15 May 2021) and there was breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider assessed the staffing levels at night in line with people's dependency needs to ensure they were receiving the care they needed in a timely way. At this inspection we found the provider had assessed the night routines for staff and made changes in night staff duties to improve.

Why we inspected

The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to investigation. As a result, this inspection did not examine the circumstances of the incident. However, we did review how the provider had learned from the incident and systems put in place to reduce future incidents.

The inspection was prompted in part due to concerns received about recording, seeking emergency support and oral care. A decision was made for us to inspect and examine those risks.

We found the provider had taken action to mitigate risks to people using the service. Please see the Safe and Well-led sections of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We undertook a focused inspection to review the key questions of Safe, Responsive and Well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last inspections, by selecting the ‘all reports’ link for The Limes Retirement Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.