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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At our last assessment the service was in breach of legal regulation in relation to people’s safe care and treatment. At this assessment the service was no longer in breach of regulation.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Improvements had been made in the systems for analysing incidents and accidents to identify potential trends. Lessons were learned and measures in place to reduce future incidents.

Discussions with the registered manager and a health professional showed there had been a reduction in falls in the service, which was confirmed by records.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Since our last assessment of this service, we had removed the restrictions on people being admitted to the service. The provider was admitting new people gradually, working with commissioners. The admission process had been improved. This included the input from people, their relatives, commissioners and staff from external services, for example if the person had been in hospital or used another care service. A person who used the service told us how they had moved from another area and had been involved in the admission process, which they were satisfied with.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Safeguarding concerns were reported as required and documented, including analysis and systems to reduce future risks.

People told us they felt safe in the service. A person said, “I feel safe, the carers make me feel safe.” Another person said, “I feel safe here, I know there is an alarm if there are any problems, I don’t use the buzzer but know it is right there next to me.” The relatives we spoke with also told us they felt their family members were safe living in the service. A relative said, “I have peace of mind that [family member] is safe and well cared for.” Another relative told us, “I am reassured [family member] is here and safe and close to home.”

Deprivation of Liberty Safeguards (DoLS) applications were made, where required and these were kept under review. This reduced the risk of people being deprived of their liberty unlawfully.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Improvements had been made in care plans and risk assessments relating to how risks were identified and mitigated. A staff member told us how the care plans and risk assessments were reviewed and updated routinely and when people’s needs had changed.

Records of how people were supported to move position to reduce the risks of pressure injury showed this was done by staff as identified in the care plan. Staff and health professionals confirmed there were no people using the service who had a pressure ulcer. A health professional told us staff were proactive and reported concerns straight away when they had identified changes in the integrity of people’s skin. This enabled the health professional to assess and monitor to reduce risks.

People’s records included personal emergency evacuation plans (PEEP) which included information about the person would they need to evacuate the building. On each person’s bedroom door there was a colour code in place relating to the level of support people required with evacuation.

The registered manager told us how the provider had purchased a chair for a person following concerns about their safety in a usual style armchair. This was done in consultation with the person, their relative and occupational therapist. This was confirmed in records, our observations and discussions with the person’s relative, who told us, “They got it in specially for [family member], [family member] fell from an ordinary chair.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Risks in the environment were assessed and measures in place to mitigate them. Records showed the environment and equipment was monitored and checks undertaken to ensure risks were reduced, such as moving and handling equipment and electrical appliances.

Improvements had been made in the signage and equipment in place to support people living with dementia to navigate around the service.

Fire drills were undertaken and equipment was in place to support the safe evacuation of the service in case of a fire.

People had access to the secure garden, the bottom of which had been closed off and not accessible to people due to the greenhouse and a summer house which needed repair. The registered manager told us this was temporary and was in place to reduce the risks to people using the service.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There was a system in place to assist the registered manager to calculate the numbers of staff required to meet people’s needs and this was kept under review. The staff rota demonstrated the staffing levels were in line with the dependency tool. Staff, people using the service and relatives told us they felt there were enough staff to meet people’s needs. A person said, “Got no problems, they look after us, staff always available any time.” A relative told us, “Always visible staff.”

Improvements had been made to ensure staff were always available in the shared area to reduce risks to people. A staff member told us, “[People} are never left alone, if a bell goes, they look for other staff to come into the lounge/dining room, they actively look to find another staff member to come in and cover them.” This was confirmed by a relative who had witnessed this happening, and in our observations.

Staff told us they received and induction and training to undertake their duties safely. This was confirmed in records. Improvements had been made in checking staff competency, for example in moving and handling, to ensure the training they had received had been effective. Where agency staff were used, they were provided with an induction, such as the fire safety of the service, and they received profiles from the agency which identified the training they had received.

Records demonstrated staff were recruited safely and the appropriate checks undertaken.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was visibly clean and hygienic and there were no malodours. Cleaning schedules were in place to reduce the risks of any areas being missed. Infection control and prevention audits supported the management team to identify any shortfalls and address them. A staff member told us about the systems in place for deep cleaning areas in the service, including people’s bedrooms. People and relatives told us they felt the service was kept clean. A person said, “There is always someone around with a hoover, they are pretty good on cleaning.”

Staff had received training in infection control and prevention.

Prior to people eating meals staff offered support to clean hands, including with wet wipes. There was a notice posted in the dining area reminding staff to offer this support.

Prior to our site visits, a local authority food hygiene inspection had been carried out, and the service were awarded the highest score.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There were systems in place to store, order, return and administer medicines safely. The medicine policy had been reviewed and updated and included guidance for staff. In addition, staff responsible for supporting people with their medicines were trained to do so safely and their competency was checked. Prior to our assessment, the service had changed to an electronic medicine management system, for which staff had also been trained in using. Medicine audits were undertaken which demonstrated any shortfalls were identified and addressed.

People told us they were satisfied with the way their medicines were managed, and they received their medicines when needed. A person said, “If in pain I can have a paracetamol.” Another person told us how they managed their medicines independently; this was confirmed in records and monitoring with the person to ensure they remained happy with the arrangements.