The Limes Retirement Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Inadequate. At this assessment the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to people’s safe care and treatment and governance at the service.

This service scored 41 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Whilst systems had been introduced to review incidents, accidents and concerns these were not used proactively to identify and manage risks to people’s safety. Where safety events had occurred these were not always robustly investigated, to look at the root cause of what happened. Incidents were not used as an opportunity to put things right, learn from and improve outcomes for people. For example, incident reports showed 3 people over a 4-month period had spilt hot drinks over themselves. Whilst these people had not come to harm, limited measures had been considered in relation to the prevention of scolding from hot drinks other than to instruct kitchen staff to ensure drinks were not hot when they left the kitchen.

Monthly falls analysis reflected there had been a reduction in the number of falls since our previous inspection in July 2024. However, the analysis was still not identifying themes and trends, and actions taken to minimise the risk of falls, other than the provider making referrals to the falls team and the GP. A relative told us, “[Family member] has had a couple of falls, they were falling out of the chair.They didn’t offer any solution to this.” Analysis completed monthly from February 2025 to April 2025 did not reflect lessons learned to improve practice and outcomes for people where their mobility had changed. For example, 1 person had 2 falls in March 2025, both occurred in the dining room / lounge area. Another person fell twice in their bathroom in February 2025. There was no further analysis, to explore the circumstances of these falls to ascertain if both people had been adequately supervised, or if they required additional support to prevent further falls.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Due to restrictions placed on the provider to prevent admission of any new people to The Limes without the prior written agreement of the Commission, only 1 person had been admitted to the service since our last assessment of the service in July 2024. Relatives told us, their views had not always been sought previously and taken into account when their family members had moved to the service, to ensure continuity in their care. Comments included, “I don’t know anything about a care plan” and “I think [Family member] might have had something drawn up when they were first admitted.” The registered manager told us they had developed new systems to ensure people moving to the service would receive person-centered care and treatment appropriate to their needs, and personal preferences. A more robust pre-admission assessment had been designed to look at people’s needs in more depth before they moved into the service to ensure their specific needs could be met. The new processes also included the involvement of the local authority and families to ensure there was a joined-up approach to ensuring people’s care and support was planned and organised in ways that ensured continuity of care, when moving from home or between services.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Although concerns were shared quickly and appropriately with the local authority safeguarding team, understanding of safeguarding and how to take proper action still needed to improve. The standard of recording of incidents and subsequent internal investigations remained poor. There were no formal processes in place to ensure safeguarding concerns were dealt with thoroughly, used to improve care for others and make sure people were protected from the risk of harm, abuse and neglect. Where concerns about people’s safety did not meet the safeguarding threshold there was not a thorough review of the incident to see what went wrong, remedy the situation, protect people, prevent further occurrences and make sure improvements were made as a result. For example, a person’s dementia care plan showed they sometimes expressed frustration through their behaviour. Incident records showed they had assaulted staff and other people using the service on 13 occasions between November 2024 and February 2025. There had been no analysis of what had happened, what had triggered these assaults, and no action plan had been implemented to address any learning to prevent further incidents to keep people safe.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s safety were still not being identified and managed well, in a timely way, with the potential for risks being overlooked. Although people’s care records were being reviewed periodically, risk assessments and associated care plans continued to lack sufficient detail for staff to understand what the risk to the person was, and what was expected of them to reduce the risk and provide proper and safe care. Where changes in people’s needs had led to increased risks to their safety and welfare, these had not been identified and acted on to reduce the risk of harm to them. For example, the night staff meeting minutes, highlighted a person’s increasing difficulties to stand. Their mobility care file and risk assessment had been evaluated to reflect they were at high risk of falls, however there was no reference to their fluctuating mobility difficulties, including poor strength when using grab rails. There were no interim care planning arrangements in place regarding use of other moving equipment to keep them safe whilst awaiting a physiotherapist review, which placed them at risk of harm from falling.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Improvements had been made to the premises, facilities and equipment, including a new wet room to support the delivery of safe care. However, further work was needed in relation to design and decoration of the premises to help people living with different stages of dementia navigate and remember their surroundings, such as contrasting colours and recognisable objects. Fire safety had improved. The fire risk assessment had been reviewed, with input from the fire service and all recommendations, including carrying out regular fire drills had been actioned. Staff confirmed they were taking part in regular fire drills and were able to describe procedures to safely evacuate the building in an emergency, including the use of equipment, such as evacuation chairs. People’s personal emergency evacuation plan’s (PEEP) had been reviewed and now included all relevant information specific to the individual for a safe evacuation in the event of a fire .

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

People’s relatives and staff told us staffing numbers had improved since our previous inspection. One relative commented, “There was a time when there wasn’t enough staff, but it seems better now.” However, 2 relatives raised concern although there were more staff, they were not always visible in the lounge when incidents occurred, or people needed assistance. Incident reports confirmed there were still occasions where there was no staff oversight in communal areas to manage safety issues, such as falls, spilling hot drinks and where people communicated their emotions or distress through their behaviour. A relative told us, “There are enough staff around, but they are not always in the room when incidents happen. I saw a person slap another resident. I went to the office to call someone; 3 carers came but it was too little too late.”

Staff told us and records confirmed, they had completed a range of training to ensure they had the skills to carry out their roles, including an introduction and the basics about dementia. Staff had completed training for dementia, however our observations showed, although well-meaning, they were still not confident on how to support people with advancing dementia, including where they communicated their needs, emotions or distress through their behaviour, and how to manage this in a positive way. There were no systems in place to assess the quality of the training provided and ensure staff understanding to ensure they had the skills, knowledge and competence to support people properly and safely.

Recruitment processes had improved since the previous inspection, ensuring all staff had robust checks carried out to ensure they were safe to work with vulnerable people and suitably experienced to carry out their roles.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Systems for assessing and managing the risk of infection were still not used effectively in line with current national guidance. The manager’s daily walk arounds failed to identify poor cleanliness and infection prevention and control (IPC) issues to ensure people were protected as much as possible from the risk of infection. The cleanliness of the kitchen and equipment was raised at our previous assessment of the service in July 2024. Whilst action had been taken to deep clean the kitchen, some areas remained unclean and unhygienic. Staff, including catering staff were unaware of their roles and responsibilities about the cleaning of the kitchen. There was no staff allocated responsibility to oversee the cleanliness of the kitchen and equipment.

Where concerns about poor cleanliness and infection control had been raised by partner agencies, these had not been acted on promptly to improve the safety of the service. For example, the District Council Environmental Health had visited the service on 16 September 2024 and made a recommendation to repair or renew the back door edging in the kitchen which leads to the courtyard outside. At the time of our visits, in March and April 2025, this had not been completed. The edging remained in a poor state, with rotting wood creating a risk for bacteria and other microorganisms to develop, potentially leading to an increased risk of the spread of infection. Our earlier assessment of the service in July 2024 had highlighted significant IPC issues. Similar issues were found in the IPC audit carried by the Integrated Care Board (ICB) Infection Prevention Control Team on 14 November 2024. However, the necessary improvements to address these concerns had not been carried out until pointed out by the ICB Infection Prevention Control Team. Failure to keep robust infection control practice placed people at risk of harm.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Since the last assessment, management of people’s medicines had improved. However, the medication policy still needed amending to ensure medicines were administered following relevant legislation and national guidance. Changes to the medication policy had been identified at our previous assessment, which included adding information about expiry dates of long-term topical medicines, such as creams and how long they should be in use to ensure they remained fit for use, the frequency-controlled drug checks should take place and the process for ensuring people have all the correct medicines when admitted to the home.

People were treated with dignity and respect during medicine administration and staff took time to explain and reassure people. Medicines were given considering people’s individual needs and preferences. Recording on Medication Administration Records (MAR) and topical (creams / lotions) medicines charts had improved ensuring correct information about people’s medicines was being kept. People’s medicines records now held relevant guidance for staff where they were at risk of falls and the potential risks from prescribed medicines such as anticoagulant (blood thinning) medicines used to prevent blood clots and prevent strokes. Where time specific medicines to treat and prevent osteoporosis and thyroid hormone deficiency were previously being administered together against pharmaceutical advice, these were now being administered separately. Charts for medicine patches to treat mild, moderate, and severe dementia, and pain had been implemented to ensure they were being applied correctly and checked daily. Protocols had been put in place to support staff to know when to administer ‘as required’ (PRN) medicines, such as paracetamol.