The Limes Retirement Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At our last assessment the service was in breach of legal regulation in relation to governance. At this assessment the service is 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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us how they felt supported by the registered manager and each other. A staff member said, “We are like a family, it has got a home environment.” Staff told us how improvements had been made in the service which they felt was positive for the staff team and the people using the service, which had also improved morale. A staff member told us how they felt the improvements had been embedded in practice because the staff team worked together and understood the requirements of their role.

Since our last assessment of this service, the induction process included advising staff of the aims, values and strategy of the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager told us about the improvements made in the service which were kept under review. They understood their roles and responsibilities of being a registered manager and felt supported in their role. The provider had employed a consultant who had worked with the registered manager in delivering the required improvements. The registered manager told us how they kept up to date with changes in legislation and good practice, this included receiving updates from recognised bodies in the care industry. They had also signed up for registered manager forums and had attended a meeting earlier in the year.

Without exception, we received positive feedback from staff, people using the service and relatives about the registered manager and their approach, which they found was caring. We saw the registered manager was visible in the service and people and relatives clearly knew who they were and communicated with them in a friendly manner. A relative told us they were able to access the registered manager when they needed to, included contact when they were not present in the service, “Communication is good, if [registered manager] not on I can ring or message [their] mobile.” Another relative told us how they felt the registered manager had gone over and above what they were expecting by offering support to the relative. In addition, we observed the registered manager spending time with a relative of a former resident of the service, which the relative told us they found supportive and caring.

A staff member told us, “[Registered manager] is an excellent carer, a good person, who takes [their] duties very seriously and is very conscientious.” Another staff member said, “[Registered manager] is so supportive, [registered manager] supports staff.” We heard from staff examples of the ways the registered manager provided support to staff, including with personal issues and when they needed assistance to travel to and from work.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager told us they had an open-door policy and were available to staff, people and relatives where needed. This was confirmed by feedback we had received during our inspection. There were systems in place to receive feedback about the service provided and use comments from people using the service, relatives, staff and other professionals to improve.

Staff told us they would not hesitate to report concerns to the registered manager, felt they would be listened to, and their concerns would be addressed. This was also the case for relatives we spoke with.

There was a whistleblowing policy in place and staff told us they understood this and would report any bad practice if needed. There were notices in the service regarding speaking up and how individuals could report any concerns.

There were boxes in place in the entrance hall of the service where people could post, anonymously if they chose, concerns, suggestions and compliments. The registered manager told us this was a new system, and they checked the boxes, but so far, no comments had been received. People and relatives were made aware of this in the new monthly newsletters which kept people up to date with any changes in the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt they were treated equally and worked well together as a team. The registered manager told us how they worked to support the staff team, including ongoing building of staff morale and a positive working culture. The registered manager, as well as their presence during the day, visited the service during the night shift, held night staff meetings and made themselves available for staff who worked at night.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Improvements had been made in the governance systems in the service. This included a range of audits undertaken by the registered manager, which assisted them to monitor the service provided. Where shortfalls were identified an action plan was in place with targets for addressing them. In addition, the consultant employed by the provider undertook audits on behalf of the provider, these also formed an action plan where improvements were needed, and these were kept under review.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager told us how they worked in partnership with other professionals involved in people’s care, including health and social care professionals. This was confirmed in feedback we received from a commissioner and two health care professionals. A health care professional told us staff made appropriate referrals and acted on guidance provided.

The registered manager told us how they were looking at strengthening community involvement, this included working with a pre-school to organise visits to the service and people living there.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Improvements had been made since our last assessment of this service. This included in governance systems, staff training and competences, care planning, lessons learned and analysis of incidents. New bedding had been purchased and were colour coded in different areas within the service. The service’s improvement plan identified the actions completed, and the progress of those not yet finished, and/or new items identified through audits. The registered manager told us of their commitment to continuously improve the service and to maintain those already made. This demonstrated ongoing learning and improvement of the service.

Staff received training relevant to their role and their competency checked to ensure the training received was effective.