This inspection took place on the 14 and 16 November 2018 and was unannounced on the first day. During our last inspection in October 2017 we found the service was in breach of regulations. Care and treatment was not provided in a safe way. Manual handling was not carried out in a safe way to avoid injury to people. Nutritional needs of people were not always met and the service did not have systems in place to monitor care. We found during this inspection the service had made improvements and was now meeting the regulations.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective and well led to at least good.

Lime Tree Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates 23 people in one adapted building across two separate units, each of which have separate adapted facilities. The units specialise in providing care to people living with dementia. At the time of our inspection there were 19 people using the service. The service changed ownership on 6 June 2018.

The service is required to have a registered manager to manage the service. 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 and relatives gave positive feedback about the service. People told us that they felt safe because steps had been taken to improve the security of the building, doors leading to the stairs were now locked to prevent accidental falls and they were surrounded by caring staff. One person commented “I feel safe because now they lock the stairs off and people can’t get up or fall down them.” A relative said, “The atmosphere makes the place feel safe. Lime Trees has what it takes- not an old peoples’ place it is a home.”

Staff we spoke with understood the importance of treating people as individuals irrespective of their lifestyle or physical and mental abilities. The service had policies and systems to guide staff. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Robust recruitment procedures meant that only suitable staff were appointed. People were supported by suitable numbers of staff who had received training to enable them to provide high quality care. Medicines were managed appropriately people received their medicines as the prescriber intended.

We saw people had a choice of meals and said they had plenty to eat. Food was sourced locally and was cooked fresh on the premises. People who required specific diets were monitored to ensure they consumed adequate nutrients. Snacks and drinks were available throughout the day.

Activities and social events were available for people to avoid social isolation. Families and friends could visit without restriction.

There was a procedure in place to allow people to make comments or raise an issue. Relatives and people told us they knew how to make a complaint if the need arose. The service had systems and processes in place to record and learn from incidents and accidents that identified trends and helped prevent re-occurrence.

People were able to attend outside healthcare visits to ensure their needs were met. The provider had systems in place to ensure the service offered quality care and support. Where issues were highlighted the service took action to enable improvements to be made.

The inspection took place on 17 and 19 October and was unannounced.

The service was previously inspected in August 2016. At this inspection we found the provider was in breach of not meeting the requirements of the regulations at that time. We found the provider breached Regulation 18 as reportable incidents were not always notified to CQC. The provider breached Regulation 15 as the service did not ensure that all risks in relation to premises and equipment were assessed and reduced. The provider breached Regulation 17 as service did not have robust systems in place to monitor the quality of the service to drive improvements. The provider was requested to send us an action plan to address these findings.

During this inspection we found the provider had addressed some of the issues from the previous inspection and improvements had been made. However, we found the provider was still not meeting regulations in other areas.

Lime Tree Court is a care home registered to provide care and accommodation for up to 23 older adults some of whom who are living with dementia. At the time of our inspection there were 18 people living at the service.

The service had 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.

Medicines were not always managed according to best practice guidelines. For example, where people were prescribed their medicine ‘as required’ (PRN) a protocol within people’s medicine charts was not in place to guide staff.

Staff did not always follow correct procedures when they transferred people. We saw staff assisting a person from their chair using a manoeuvre that put the person at risk of injury.

People at risk of malnutrition did not have a fortified diet to ensure additional calories were given to reduce the risk of further weight loss. In addition input from professionals was not sought to monitor and review their weight loss.

The provider did not have effective systems in place to monitor the quality of care and support that people received. Audits were not carried out to identify any shortfalls.

People told us they felt safe, comfortable and well cared for at Lime Tree Care Home. One person told us, “I feel safe and happy here.”

People benefited from a safe service where staff understood their safeguarding responsibilities. Staff we spoke with told us they would not hesitate to raise a concern. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Healthcare professional we spoke with told us they had no concerns. A visiting professional said, “The girls here are great this is a very good service.”

Staff demonstrated kindness and compassion towards the people they were supporting. We observed staff to spend quality time with people and did not rush them. The services activity coordinator was not working at the service at the time of our inspection due to long term absence. However, staff supported people to engage in activities during their absence.

We found breaches of the Regulations of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 23, 30, 31 August 2016. It was an unannounced visit to the service.

We previously inspected the service on 4 July 2014. The service was meeting the requirements of the regulations at that time.

Lime Tree Court is a care home for older adults who are living with dementia. It is registered to provide accommodation for 23 people. At the time of our inspection 20 people lived at Lime Tree Court.

The service had a registered manager in post; however, they had been away from the service for a period of time. 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.

The provider did not always ensure it assessed and reduced the potential risks to people in its care. No Legionella risk assessment was in place. The service had received positive water samples for the non- lethal strain of Legionella. It had responded to actions required to ensure this was reduced. However it had not adequately identified a competent person to take the lead in managing the risk.

Environmental risk assessments were not routinely assessed or reviewed to minimise risks to people. However equipment used was serviced in line with manufacture’s guidelines. We found the service did not always protect people from potential risks. For instance, open bottles of toiletries were left in communal bathrooms.

The service did not always ensure all the required pre-employment checks were undertaken, this could have led to staff not being suitable to work with people. However it did always seek a reference from a previous employer which reduced this risk.

Providers are required by law to inform the Commission when certain events occurred. We checked our records and found we had not routinely been informed of events which we needed to be aware of.

Records were not always maintained in a way that supported good governance of the service. There was a mixture of old and new paper work. It was sometimes difficult to know which was the most updated version of forms being used.

People received their medicine when needed; we observed some good practice regarding the administration of medicine. The service did not ensure that old stock was used before newly dispensed medicine. We have made a recommendation about this in the report.

Staff told us they felt supported by the management, however records relating to support provided to staff did not support this. We have made a recommendation about this in the report.

We received a lot of positive feedback about how homely the service was. Comments included “I couldn’t be looked after better,” “This is a wonderful care home” and “I’ve loved it, from the day I moved in.” Staff understood people’s needs as they had worked with them for a long time. Staff were able to communicate to people on a level that was understood.

Staff demonstrated kindness and compassion and promoted people’s independence and dignity. Staff had a good understanding of how to keep people safe and free from abuse. They told us they would not hesitate to raise a concern.

People were supported to engage in meaningful activities. Relatives told us they liked Lime Tree Court as it was “Homely” and “Welcoming”. Healthcare professionals spoke highly of the personalised care people received. This was supported by comprehensive care planning. Staff were supported to understand people’s needs as likes and dislikes were clearly recorded in care plans.

We found breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). The provider told us they had not had a need to make an application to deprive anyone of their liberty but in light of recent changes in legislation, they would seek advice from the DoLS Supervisory body.

People who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. People told us they felt safe and had no concerns. Safeguarding procedures were in place and staff understood their role in safeguarding the people they supported. We viewed the staff training matrix which showed all staff were provided with safeguarding training. This ensured staff had the knowledge and skills to respond to any allegations of abuse appropriately.

These findings demonstrated to us that the service was safe.

Is the service effective?

A pre-admission assessment of people's needs had been undertaken before they moved into the home. The manager visited people in their own homes, or in hospital before they were admitted. This enabled the manager to discuss people's needs with them and/or their family and next of kin. This enabled people to discuss the services provided at Lime Tree Court and their individual needs and how they wished them to be met.

People received co-ordinated care. We saw evidence in people's care plans which demonstrated people had been visited by their GP and other health care professionals and appropriate advice sought when required

We found the care and support provided was reflective of people's needs detailed in their care plans. Where any changes in their health and social care needs were evident, their care plans had been updated to reflect the change in their needs and how they were to be supported to meet them. Any accidents or incidents were recorded appropriately detailing the actions taken and risk assessments had been updated documenting any further measures put into place to prevent a recurrence.

It was evident through discussions with staff and through observing their interactions with people that they had a good relationship and understanding of everyone's needs and knew them well.

These findings demonstrated to us that the service was effective.

Is the service responsive?

The provider was responsive to people's individual needs in relation to their health,social care and personal care needs. Records had been maintained of appointments with health care professionals and any advice given was recorded and care plans updated to ensure their needs were met appropriately. People were consulted with in relation to the choice of activities provided. This ensured their individual social needs were catered for according to their preferences and interests. Any accidents and incidents were recorded and investigated appropriately. They detailed the actions taken and risk assessments had been updated to document any further measures put into place to prevent a recurrence.

These findings demonstrated to us that the service was responsive.

Is the service caring?

Throughout the day we observed staff interacting with people living in the home. Staff were seen to be talking and supporting people in a kind, gentle and attentive way. Staff showed patience and encouragement when supporting people and had a good understanding of people’s needs and knew them well. Comments from people who used the service included ''The carers are kind, sometimes I wonder how they put up with us all.'' ''We're safe, everything is fine...the food is good, the staff are good they look after us really well what more can you ask for.'' A relative we spoke with was happy with the care and support their relative received and told us '' We have no complaints and the staff are lovely.''

These findings demonstrated to us that the service was caring.

Is the service well led?

The provider was very much involved in the day to day care provided, by talking to people and their relatives, speaking with staff and observing their practices. This meant any issues raised or observed could be dealt with immediately.

People's views were actively sought through regular monthly reviews of their care and support, annual questionnaires and on a general day to day basis. This enabled people to review the quality of the services provided and make suggestions where improvements could be made.

People's care plans were reviewed on a monthly basis and updated where any needs had changed. This ensured the service maintained an accurate record in respect of each service user needs.

Systems were in place to log and record accidents, incidents and complaints and the actions that had been taken in response to these. This enabled the provider to assess the types of incidents and complaints and enabled them to learn from them to minimise the risk of any possible recurrence.

We saw various health and safety checks were undertaken. For example, we saw the lift, hoists and assisted bath were regularly checked and serviced. This ensured equipment was in good working order and safe to use. We saw systems were in place to regularly check the fire doors, the fire alarm system and regular fire drills were undertaken.

Daily cleaning routines were undertaken and daily checks were completed. This was to ensure the environment remained clean and free from risk of cross infection. This meant the service had appropriate systems and processes in place for gathering, monitoring. recording and evaluating the quality of services they provided.

These findings demonstrated to us that the service was well led.

People’s care and support needs were assessed and delivered in line with their individual care plans. These were detailed, regularly reviewed and updated. Risk assessments were in place to identify and reduce the likelihood of injury or harm with guidelines in place for staff to follow.

People had access to healthcare professionals and specialist support to ensure their health and wellbeing. A visiting GP told us ''We have a good working relationship''. They further said they had no concerns about the care provided and stated the home was ''very well run, everyone is well cared for and they treat them with respect.''

There was a wide range of daily activities provided for people to take part in if they wished. They included one to one activities and group sessions both within and outside the home. They were tailored to people's likes, dislikes and individual needs to ensure their social care needs were met appropriately.

Systems were in place to regularly assess and monitor the quality of service that people received to ensure people benefitted from safe quality care and support.

People we spoke with, including visiting relatives described the care they received as "very good." One relative told us they were happy with the care their relative received. They told us staff were ''Very good and have the patience of a saint''. The relative said staff took their time to engage and communicate with people who had communication difficulties.

Many people who used the service had dementia and as such found it difficult to express their views about what it was like living at the home. Five people we spoke with told us staff were polite, respectful, and encouraged them to do us as much as they could for themselves.

During our visit we saw staff assisted people in a kind and compassionate way. We saw people were treated with dignity and respect. We joined people in the dining room at lunch time. We observed staff offered people choices of food and went out of their way to provide one person with a meal which they liked. People were not rushed and were able to eat their lunch at their own pace.

People’s needs had been assessed before a placement at the home had begun and included risk assessments. This ensured their needs could be met appropriately. Care plans addressed people's individual needs, were detailed, reviewed and updated regularly. People had access to healthcare professionals and specialist support to ensure they kept healthy and well.

There were systems in place for the management of medicines. However, during the course of our visit we found a discrepancy in the total number of one person's medication held. Actions were taken swiftly to ensure the person had received their medication as prescribed.

Daily activities were provided for those who wished to take part. These included one to one activities and group activities. Family and friends were welcomed and invited to events in the home.

People told us that they and/or their family members had been given the opportunity to visit the home before they moved in to ensure it met with their needs and expectations. They said staff had discussed their preferred routines and their individual needs and were satisfied with the care and support they received. They said that they were supported to access health services when required and enabled to take part in activities. People told us that the staff treated them as individuals and respected their views and choices. They said that they felt safe and that staff looked after them well.