- Care home
The Limes Retirement Home
Assessment report published 22 July 2025
Contents
Ratings
Our view of the service
Date of Assessment: 04 March 2025 to 28 May 2025. The Limes Retirement Home is a residential care home providing accommodation and personal care for up to 26 older people, including people living with dementia. The service is made up of the main building and 2 single accommodation cottages within the grounds. There are other cottages onsite, but the provider is not allowed, under their registration, to provide personal care to the people who live in them. At the time of our visits there were 17 people using the service.
This assessment was carried out to check if improvements had been made to the service following our previous assessment in July 2024 and the urgent enforcement action taken to ensure people’s safety. The provider was previously in breach of the legal regulations in relation to safety, the premises, safeguarding, staffing numbers, recruitment, training, person centred care, management and governance. Although some improvements were found at this assessment, the provider remained in breach of regulation, the breach was in relation to management and governance of the service. We found further breaches of regulations relating to person centred care, consent, safe care and treatment and staff training.
Systems implemented to assess, monitor, improve and sustain the quality and safety of the service were not being used effectively. Complaints were not always thoroughly explored, responded to and acted on to make improvements. Where people’s needs changed, risks to their health, safety and welfare were not consistently identified and mitigated. Safeguarding concerns, incidents and accidents were not being used as an opportunity to learn from, put things right and manage risks before safety events happened. Improvements had been made to ensure there was more staff available to meet people’s needs. However, there were no systems in place to assess staff understanding of training provided and ensure they put learning into practice to enable them to carry out their roles effectively and safely. Improvements had been made ensuring the facilities and equipment were maintained, however further work was needed to ensure the premises, including the kitchen were clean to protect people from the risk of infection. People’s medicines were managed safely. The service cared about and promoted the wellbeing of their staff and staff told us they enjoyed their roles.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
This service has been in Special Measures since 14 January 2025. The provider demonstrated enough improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
People's experience of this service
We used the short observational framework for inspection (SOFI) to assess whether people were receiving good care. Staff treated people with kindness but did not always promote their privacy and dignity. On occasions care was provided by staff in a task focused way, rather than meeting people’s individual needs and preferences. While people we spoke with and their relatives expressed general satisfaction with the care provided, our assessment found people’s care was not always meeting the expected standards. People’s individual needs and preferences, especially those living with dementia were still not being fully understood and reflected in the care and support they received. Where people communicated their needs, distress or emotions through their behaviours this was not always being managed in a positive way.
Relatives remained concerned there was not always enough staff oversight of communal areas to meet people’s needs and prevent falls. Further work was needed to ensure people’s care plans fully reflected their physical, mental, emotional and changing needs to enable staff to provide the right care, and consistent support to keep people safe. People, and their relatives had not always been included in discussions about important life changes, such as their preferred end of life care. People’s capacity and ability to consent was not always carried out in line with the requirements of the Mental Capacity Act (MCA) 2005 to ensure decisions about their care, treatment, and support were understood and respected. The service continued to have a good working relationship with other health professionals, including the local GP practice ensuring people had regular reviews of their health and wellbeing needs.