We inspected Lime Tree House Residential Home on the 22 May 2017and the inspection was unannounced. Lime Tree House provides accommodation for up to 30 older people. On the day of our inspection there were 28 people living at the service. Lime Tree House is a residential care home that provides support for older people. Some people had illnesses or disabilities associated with old age such as limited mobility, physical frailty or lived with health problems such as heart disease, diabetes and strokes. Some people lived with dementia and sensory impairment. Accommodation was arranged over two floors with stairs and a lift connecting each level.

The service had a registered manager. 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.

At the last inspection on the 17 October 2016, the service was rated Good overall and Requires Improvement in the 'well-led' domain. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lime Tree House Residential Home on our website at www.cqc.org.uk

The service had improved their quality assurance framework. Care plans were now updated regularly and provided robust guidance for staff to follow. Fluid charts were now totalled at the end of each day and nutrition care plans had considered people’s daily fluid intake target.

Systems were now in place to mitigate the risks relating to health, safety and the welfare of people living at the service. Weekly health and safety checks were taking place and concerns raised at the last inspection in October 2016 uneven flooring had been addressed.

People, staff and relatives were complimentary about the leadership and management of the service. One staff member told us. “The manager is one of the best manager’s I’ve ever had.” A visiting relative spoke highly of the leadership style of the manager reflecting that they made themselves available and were visible within the service.

Forums were in place for people, relatives and staff to provide feedback on the running of the service. Feedback was then used to drive improvement and improve the quality of care that people received.

There was a friendly, warm and homely atmosphere and a positive culture. Staff described the key strength of Lime Tree House as its welcoming and friendly atmosphere. One staff member told us, “There is a strong family atmosphere here which I really enjoy.”

We inspected Lime Tree House Residential Home on the 17 October 2016 and the inspection was unannounced. Lime Tree House provides accommodation for up to 30 older people. On the day of our inspection there were 28 people living at the home. Lime Tree House is a residential care home that provides support for older people. Some people had illnesses or disabilities associated with old age such as limited mobility, physical frailty or lived with health problems such as heart disease, diabetes and strokes. Some people lived with dementia and sensory impairment. Accommodation was arranged over two floors with stairs and a lift connecting each level.

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.

The provider’s quality assurance framework was not consistently effective or robust. Shortfalls and omissions in documentation were evident. Risks associated with the environment had been identified but not acted upon, placing people at risk of falling.

People commented they felt safe living at Lime Tree House. People commented positively about the care, treatment and support received. One person said, "Yes, I have a safe room and the corridors are excellent.” A range of risk assessments were in place, however, the risk management of skin breakdown was not robust. We have made a recommendation about risk assessments.

Staff demonstrated good knowledge and understanding of the Mental Capacity Act (MCA 2005). One staff member told us, “We have to assume a person has capacity until proven otherwise. If a decision is made on their behalf it has to be in their best interest. People can make an unwise decision but it doesn’t mean they lack capacity.” However, mental capacity assessments were not completed in line with legal requirements. We have made a recommendation about the completion of mental capacity assessments.

Care and support was provided to people living with dementia, however, improvements were required to make the environment dementia friendly. We have made a recommendation about sourcing input from a national source on dementia friendly environments.

People we spoke with were complimentary about the caring nature of staff. People told us care staff were kind and compassionate. People were treated with respect when they received care. One person told us, “Staff are kind and caring at all times.” Dignity champions were in post and the registered manager worked with Skills for Care to promote awareness and understanding of the importance of privacy and dignity.

Systems were in place for the safe storage, administration and disposal of medicines. Records showed people received their medicines as prescribed and in their preferred manner. People had access to healthcare services to maintain good health.

People were protected from the risk of harm and abuse. Staff had received safeguarding adults training and were aware of their responsibility to report any concerns. Policies and procedures were in place to advice staff on what they should do if they had concerns. Safe recruitment practices were followed before new staff were employed to work with people.

People, staff and relatives were complimentary about the leadership and management of the home. A staff member told us, “I feel supported by the team I could go and ask any of the care workers or seniors or manager for help at any time. Everyone is so kind and supportive.”

Positive relationships had been developed between people as well as between people and staff. There was a friendly, caring, warm and relaxed atmosphere within the home and people were encouraged to maintain relationships with family and friends. A wide range of activities were ava

We looked at six care plans for people who used the service, the service's policies and procedures, staff files and training records. We spoke to the manager, four members of staff, two relatives and six people who used the service.

People's consent was sought appropriately. People told us, "They always make sure I consent before they do anything and I can always change my mind". We saw people's consent or refusal were recorded and care was delivered in line with their agreed care plans.

People experienced care, treatment and support that met their needs and protected their rights. A relative told us, "The care is very good here, my relative is well cared for, they are kind and patient towards her and got to know her well".

We found that people who used the service were provided with a choice of suitable and nutritious food and drink. One person told us, "The food is always hot, and it is often too much, but it is always tasty". A relative said, "My mother eats well here, the menus are good and all the food is freshly cooked".

The service had a safeguarding policy for the protection of vulnerable adults. Staff were trained appropriately and were aware of their responsibilities in respect of safeguarding. One member of staff said, "I would not hesitate in talking to the manager straight away if I felt any abuse was taking place, or to social services".

Staff received appropriate professional development and were appropriately supported.

During our visit we talked with six people who lived at Lime Tree House, two relatives, seven members of staff and the manager. We observed staff interacting with residents who told us how satisfied they were with the level of care they received and how respectful of their wishes the staff were. One person told us “I like it here, they are ever so kind and although it’s not home it’s the next best thing. I have made friends for life in this place, you are never lonely here, the staff are lovely’”. Another two residents said “they listen to us here, we get to choose what we want at mealtime and it is always hot”. One resident remarked that although staff understood what was needed, she could not always understand the staff but felt she was able to talk to the manager if she had a problem. One relative said “we are always welcome to visit, we have a say with what is going on, we feel involved”.

Residents described the activities which were provided for them to participate in although one person told us “I do not join in the activities I prefer to stay in my room with the door open, the staff often check on me and bring me a cup of tea, we have a chat”,

When we asked people to describe the meals they told us how they were consulted and how their preferences were taken into account. The feedback we obtained was complimentary and included “The food is superb, always hot and nicely presented, we can choose in advance what we prefer”.

The visit was carried out by one Inspector over the course of five hours. During this time we (i.e. CQC) talked with nine people living in the home, one relative, one visiting health professional and four staff as well as the manager and the proprietor. The home’s manager was available throughout the visit; and we talked with the proprietor during the morning.

People living in the home made very positive comments including the following:

“All the staff are very good to me. The manager is excellent, I can always ask her anything.”

“It is very comfortable here. There are usually plenty of things to do for people who want to join in; but you don’t have to join in if you don’t want to.”

“All the staff are very good. I can always ask to talk to the manager if there is anything that needs sorting out, and I know she will do it for me.”

“I am happy living here, even though it was difficult to leave my own home behind.”

A relative said: “I have nothing but praise for the staff here. It is all excellent, 100%. It is very comfortable here, and I am very happy with the care that is given. The staff contact me if there are any concerns, and usually e-mail me regularly, as that is how I prefer to be contacted.”

A visiting health professional said: “It is always very good care here.”

Some written comments on recent questionnaires included:

“Mum is very happy here, and I am very impressed with her care and that of others in the home.”

“The carers are polite, hard-working, and have a good sense of humour.”