About the service:

Lime House provides accommodation for up to 32 people who require personal care. The home is part of Nugent Care and the head office is based in Liverpool. The home has a main house connected by link corridor to a lodge and is surrounded by secure landscaped gardens. There is a choice of several lounge and sitting areas throughout the home. At the time of the inspection 27 people were living at the home.

People’s experience of using this service:

Appropriate systems were not in place to monitor accidents and incidents.

Risk assessments and care plans were not always updated when changes occurred.

Nutritional records were incomplete and food and fluid intake was not always being monitored.

There was no evidence available to show that when something had gone wrong the registered manager responded appropriately.

The principles of the Metal Capacity Act (MCA) were not always being followed.

Although we found people appeared well cared for, it was not always clearly documented in the care records we saw, how people were involved in making decisions about their care.

End of life care discussions had not always been undertaken in a timely way.

Audit and governance systems were not effective as the provider had not identified and resolved the concerns we found during this inspection. Quality assurance systems needed to be improved to ensure any concerns were identified and acted upon in a timely manner.

Staff were recruited safely and there were sufficient numbers of staff to care for people safely.

The building and the premises were monitored, however, maintenance certificates for the passenger lift were not up to date.

Staff received the necessary induction, training, supervision and appraisal to support them in their roles.

People living at the home and visiting relatives made positive comments about the care provided at the home.

There were a range of activities available for people to participate in.

We received positive feedback from people we spoke with about management and leadership within the home.

More information is in the full report.

Rating at last inspection:

Good (report published 30 September 2016). The overall rating for the service at this inspection is requires improvement.

Why we inspected:

This was a planned inspection based on the rating at the last inspection. At this inspection we identified some areas which required improvement.

Enforcement:

We found five breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to person-centred care, need for consent, safe care and treatment, safeguarding, nutrition and hydration and good governance. We also found a breach of the Care Quality Commission (Registration) Regulations 2009. We have also made recommendations about the management of medicines and involving people in making decisions about their care and treatment. Due to the number of concerns identified, following the inspection we wrote to the provider to seek an immediate response to our concerns and we received a reply.

Please see the ‘action we have told the provider to take’ section towards the end of this report.

We issued a warning notice in response to the regulatory breaches identified during this inspection.

Follow up:

We will ask the provider to complete an action plan to show what they will do and by when to improve the five key questions to at least good. We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

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

This comprehensive inspection took place on 23 August 2016 and was unannounced. The inspection team consisted of two adult social care inspectors. At the time of the inspection, there were 30 people living at the home. Lime House is registered to provide personal care and support for up to 32 people. The home is part of Nugent Care and the head office is based in Liverpool. The home has a main house connected by link corridor to a lodge. Most rooms were for one person and there were also up to four shared rooms. There was a choice of several lounge and sitting areas throughout the home.

At the last inspection on 29 August 2014 we found the service to be compliant with all regulations we assessed at that time.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People we spoke with said they felt safe living at Lime House. There were systems in place to protect people from abuse. There was an up to date safeguarding policy in place, which referenced legislation and local protocols.

The service had a robust recruitment procedure in place. Appropriate checks were carried out before staff began working at the home to ensure they were fit to work with vulnerable adults.

There were sufficient numbers of staff working at the home to meet people’s needs. All of the people spoken with including people living at the home, staff and visiting relatives told us they felt staffing levels were sufficient.

We looked at a sample of Medication Administration Records (MAR’s) and observed medicines administration during the day and saw that MAR’s were signed by staff when people received their medication, as required. We saw requirements relating to controlled drugs were being met. A medicines stock control form was used for each person receiving assistance with medicines. People living at the home told us they had no concerns about receiving their medicines.

We saw that care plan documentation contained risks assessments which covered Waterlow, pressure sores, moving and handling, nutrition, bathing and falls/mobility. Each risk assessment had a corresponding ‘risk plan’ which detailed how the risk was managed and any control measures that were in place.

The home was clean and tidy with no pervasive malodours present.

There was a staff induction programme in place which staff undertook when they first started working at the home and this was aligned with the requirements of the care certificate. Staff told us they received supervision as part of their work and we looked at a sample of records which demonstrated these took place.

The registered manager demonstrated effective systems to manage DoLS applications.

During the inspection we observed staff seeking consent from people before providing assistance, such as asking people if they would like to take their medication.

We observed people were treated with kindness and dignity during the inspection. Each person we spoke with said they liked living at Lime House and were happy with the care they received.

We saw that people had specific nutrition care plans in place and where required, risk assessments had also been implemented if people were at risk with regards to their nutrition.

There was a four week rolling menu in place, which was available in the dining room. Special diets were catered for, food allergies were recorded and information on different diet types.

In care plans we saw people had access to a range of different service including district nurses, podiatrists, doctors, advanced nurse practitioners, GP’s and opticians.

We saw that adaptations had been made to make the environment suitable for people living with dementia.

We found the s

This is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

We asked the following five questions.

Is the service safe?

Both the people who lived in the home and their relatives were pleased with the care provided and felt their views were respected and listened to. The staff worked in a safe and hygienic way and used appropriate protective clothing. We saw each bathroom had a lockable cabinet in which to store cleaning materials which might be hazardous to people’s health.

There were enough staff to meet the needs of the people living in the home and a member of the management team was available on call in case of emergencies. One person said: "I feel safe here. I trust them."

Staff personnel records contained all of the information required by the Health and Social Care Act. This meant the provider could demonstrate staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home.

The registered manager and the staff we spoke with understood the importance of safeguarding vulnerable adults. Staff could identify potential abuse and knew how to report any incidents of abuse.

Is the service effective?

People told us they were happy with the care they received and their care records were up to date and signed by them where appropriate. One relative said: "She’s just got better every day.” A person who lived in the home said: "I can only eat certain foods and they are very careful about that."

Care records confirmed people's preferences and needs had been recorded and care and support had been provided in accordance with people's wishes.

We heard from staff information was shared effectively. Several ways of sharing information were used including staff meetings, handovers, the handover book, daily records, and monthly reviews.

Is the service caring?

People were supported by kind and attentive staff. We saw care workers showed patience and encouragement when supporting people. One relative said: "I can’t find any fault with it. It is a really nice place." One person who used the service said: "I’m always happy in what I do here."

Is the service responsive?

People's needs had been assessed before they were admitted to the home. Their needs for support and treatment were carefully described so care workers knew exactly what tasks to undertake. Changes in people's care needs were reported to the senior carer and Registered Manager and they briefed care staff.

One person we spoke with said: "You can have anything you want." A nurse who visited the home said: “They are quick to pick up if there is something wrong with the patient.” A person who lived in the home said: "It’s been my godsend."

Is the service well-led?

Staff had a good understanding of the culture of the home and quality assurance processes were in place. We saw the results of customer satisfaction surveys completed in October 2013 and we spoke with relatives who had contributed to these. A meeting for people who lived in the home was held every month to seek suggestions for any improvements required.

Staff told us they were clear about their roles and responsibilities and were well supported. One said: "She (the manager) will support us both in work and with family issues. She has an open door policy." Another member of staff said: “If you are struggling with something they will show you.”

During our inspection we spoke with seven people living at Lime House. All of the people we asked told us they were happy with the care they received and they thought they were well looked after. One person told us “We are all OK living here. There is nothing that needs to be changed.” Another person told us “I am looked after very well. This is a good place.” We observed people being cared for in a calm and supportive manner.

When we visited in January 2013 we found that there were issues with people’s privacy and dignity; actions taken after incidents and accidents were not always recorded and care records were not always accurate. The provider sent us a plan stating that the actions that would be taken to achieve compliance and when we visited in April 2013, we found that all of these issues had all been addressed.

We saw that people were offered choices at each meal time and we were told that staff would always try to provide any special requests for food. People’s weights were checked regularly to monitor for signs of malnutrition.

The provider had taken steps to ensure that care was provided in an environment that was suitably designed and adequately maintained. One person told us “this is a lovely place to live. I am very happy with my room.”

We looked at the recruitment procedures that were followed at Lime House. We found that there was a robust system in place to ensure that appropriate people were recruited to work in the home.

During our inspection we spoke with six people and five visitors. All of the people who we asked told us that they were happy with the service they received and they thought that they were well looked after. The comments we heard included “Staff are very good“; “This place has saved my life. I am very happy living here” and “I have no complaints about the staff at all; they are brilliant.” One visitor told us “Nothing is too much trouble for the staff here.” Another visitor told us “The manager is fantastic.”

We found that people were cared for in a pleasant, clean and well organised environment. However, it was a concern to us that there no locks on the inside of some of the toilet and bathroom doors. People did not raise this with us as an issue of concern but it is clear that this does not fully respect people’s privacy and dignity.

Staff members were happy working there and they told us that they had received relevant training. They also told us that they were supported in their role and that the manager and senior staff were approachable.

We saw that there were systems in place to monitor the quality of care but these were not always updated with the frequency that the provider had set for themselves. Actions taken as a result of accident and incident monitoring were not always formally recorded and this made it difficult for us to confirm that appropriate actions had been taken and completed. Care records were not updated in a timely manner.

People who used the service at Lime House were very happy with the support provided.

People enjoyed the environment and felt that their health, emotional and social needs were met in full. People said that they felt respected and safe.

People explained:

'All the trees make it beautiful.'

'It's not like the ones you see on telly.'

'I have no complaints, the home is always kept nice and tidy,it's beautiful.'

And

'It's fine, the staff are great.'