About the service:

The Limes is a residential care home that was providing personal care to 38 people at the time of the inspection. People who used the service had physical disabilities, sensory needs and mental health needs; such as dementia.

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

People’s experience of using this service:

Improvements were needed to ensure the newly implemented systems in place to monitor the service were imbedded and sustained. Improvements were needed to ensure records were updated in a swift manner.

We recommended the provider seeks nationally recognised guidance to ensure information was consistently presented in a format to aid people’s understanding.

People were supported by safely recruited staff who had the skills and knowledge to provide safe and effective support. People were supported to manage their risks, whilst promoting their independence. Systems were in place to ensure that people received their prescribed medicines. Effective care planning was in place which guided staff to provide support that met people’s needs, which were in line with their preferences.

People consented to their care and were supported in their best interests. The provider has systems in place to ensure that people’s capacity was assessed in line with the Mental Capacity Act. People were supported to eat and drink sufficient amounts in line with their assessed needs. People’s diverse needs had been planned for, which ensured people received individualised care in all aspects of their life. Professional advice had been sought and acted on to ensure people’s health and wellbeing was maintained.

Staff were kind and caring towards people and promoted choices in line with individual communication needs. People were treated with dignity and their right to privacy was upheld.

People had opportunities to be involved in activities both within the service and in the community. People and their relatives were involved in the planning of their care, which meant people were supported in line with their preferences. Complaints systems were in place, which people and relatives knew how to use. There was no one receiving end of life care at the time of the inspection. However, people’s advance decisions were planned.

There was an open culture within the service, where people and staff could approach the registered manager who acted on concerns raised to make improvements to people’s care. Feedback was gained from people who used the service.

Rating at last inspection:

Requires Improvement (report published 13 July 2017).

Why we inspected:

This inspection was carried out to check the provider had made improvements since the last inspection.

At the last comprehensive inspection in May 2017 the service was rated requires improvement overall (in the key questions of Safe, Effective, Caring, Responsive and Well Led). There was a breach in regulation because people were not always safeguarded from potential harm. We asked the provider to forward an action plan to show how they planned to make improvements to people’s care.

At this inspection improvements had been made to meet the regulations. However, some further improvements were still needed in the key questions of Safe and Well Led. The service had met the characteristics of Good in Effective, Caring and Responsive. Therefore, the overall rating is Requires Improvements.

Follow up:

We will continue to monitor the service through the information we receive.

This inspection took place on 24 May and was unannounced. At our previous inspection in June 2015 we had concerns that the service was not consistently safe or well led as the systems the provider had in place were not ensuring that people's medicines were being managed safely. At this inspection we found that medicine management had improved however we found further concerns that meant that the service was not consistently safe, effective, caring, responsive and well led. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The Limes provides accommodation and personal care for up to 41 people. People who used the service may have physical disabilities and/or mental health needs such as dementia. At the time of the inspection 37 people used the service.

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 were not being safeguarded from potential abuse as incidents of suspected abuse had not been referred to the local authority for investigation. We raised a safeguarding referral for two people following our inspection. Following the inspection the registered manager took action to prevent further incidents.

Risks of harm to people were not always assessed and minimised. Action was not taken to reduce the risk of harm following incidents that had put people at risk or resulted in harm. People's risk assessments were not consistently followed to keep people safe.

The principles of the Mental Capacity Act (MCA) 2005 were not consistently followed. People's mental capacity was assessed, however precautions were not being taken to ensure any restrictions in place for people were the least restrictive option.

Staff felt supported and received training to fulfil their roles. However the training available was not always sufficient for the provider to be sure that staff were fully competent in the care tasks they were required to undertake.

People were not always treated with dignity and respect and people's changing needs were not always responded to in a timely manner.

The systems the provide had in place to monitor and improve the service were not consistently effective in identifying concerns and making improvements to the quality of care for people.

There were sufficient numbers of staff to meet the needs of people who used the service. New staff were recruited through robust recruitment procedures to ensure they were fit to work with people who used the service.

People's medicines were stored, managed and administered safely by trained staff.

People were encouraged to maintain a healthy diet and their nutritional needs were met. People were referred to health professionals if they experienced difficulties with eating and drinking. If people became unwell they were supported to access a range of health care services.

There was a range of hobbies and activities available to people if they chose to join in. People were involved in the planning of their care and activities through regular reviews and meetings and they were encouraged to be as independent as they were able.

People felt able to complain and confident that their concerns would be dealt with. The provider had a formal complaints procedure which was available for use.

People's feedback on the service was gained and action was taken to improve the quality of service where improvements were identified.

People who used the service and the staff felt the management were approachable and they were regularly asked their views on the service.

We carried out an unannounced inspection of The Limes on 22 June 2015. The last inspection was carried out on the 08 April 2013 and we found that they were meeting the required standards.

The Limes provides person care for up to people 41 people. People who use the service may have physical disabilities and/or mental health needs such as dementia. At the time of the inspection 37 people used the service.

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.

The registered manager had systems in place to monitor the service but we saw that some improvements were needed to ensure these were effective.

People’s risks were assessed in a way that kept them safe whilst promoting their independence.

People who used the service received their medicines safely. Systems were in place that ensured people were protected from risks associated with medicines management.

We found that there were enough suitably qualified staff available to meet people’s needs in a timely manner, which promoted their wellbeing.

Staff were trained to carry out their role and the provider had safe recruitment procedures that ensured people were supported by suitable staff.

Staff had a good knowledge of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). The Mental Capacity Act 2005 and the DoLS set out the requirements that ensure where appropriate decisions are made in people’s best interests when they are unable to do this for themselves. People’s capacity had been assessed and staff knew how to support people in a way that was in their best interests.

People told us that staff were kind and caring. Staff treated people with respect, gave choices and listened to what people wanted.

People’s care preferences were recorded throughout their care plans and we saw that people were supported to be involved in hobbies and interests that were important to them.

The provider had a complaints procedure that was available to people and people were aware of this policy.

Staff told us that the registered manager was approachable and led the team well. The registered manager and staff all had clear values and understood their role and what it meant for people.

Feedback was sought from people and their relatives and they were able were encouraged to be involved in the improvement of the service.

At our last inspection on the 20 December 2012 we found that appropriate systems were not in place to protect people from the risks associated with infection control.

During this inspection we spoke with staff, the registered manager and viewed records. We also spoke with the Infection Control Team and the Environmental Health Officer.

We found that the provider had made improvements to their systems to prevent, detect and control the spread of infection.

The provider had commenced refurbishments to the environment to ensure that people were protected against the risk of infection and cross contamination.

During this inspection, we spoke with two visitors and four people living at the home. We also spoke with three members of staff. Following our last inspection, we set compliance actions in a number of outcome areas. At this inspection, we found that a number of small changes had been made to make a big difference to life at the home. The interactions between staff and people living at the home were more relaxed and spontaneous. One person we spoke with told us, “It is better than it used to be. The staff seem to have more time to speak to me.” We found that mealtimes were more organised, providing a relaxed and social atmosphere for people. The quality of the food served had also improved significantly since our last inspection.

The standard of general cleaning and hygiene practice in the home provided a clean environment. A number of practical steps had been taken to address the daily risks of cross infection. There were some wider premises issues that needed to be assessed and responded to in support of the effective management of infection control.

A number of improvements in the management of the home were also identified. Some of the staff shift patterns had been amended and additional staff had been recruited to provide more flexibility in meeting staffing needs. We also found that clear standards for recording had been set and were being followed in the home by staff.

People told us what it was like to live at this home and described how they were treated by care staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service, and a practising professional.

On the day of our visit, the cooker at the home was not working. This meant that the home had limited cooking facilities across the day. When we first arrived at the home just before 9am, we found most people were up and dressed, waiting for breakfast. It was 10am before people were able to sit and eat breakfast. We were told by the management team that breakfast was late because of issues in the kitchen. Four people told us that it was not unusual to be eating breakfast so late.

A number of people living at the home had varying levels of dementia, so not everyone was able to tell us about their life at the home. To help us understand people's experiences we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people who could not talk with us.

We were able to speak to ten people and four relatives. All the people and relatives we spoke with were positive about the care staff. One person told us, “I don’t know what I would do without the care staff here – they’re marvellous.” One person told us that, “Everyone is so nice”, and “I feel safe and well cared for. “A relative we spoke with told us, “I enjoy coming here. I know my sister is safe.” Another relative told us that relatives and friends were always welcome at the home.

We spoke with five members of care staff. They had a good understanding of the types of abuse and their role in keeping people safe. The ongoing training of care staff reflected some of the specific needs of people living at the home. Care staff respected the day to day choices people were able to make and how their independence could be supported. We found differences in how well care staff supported people at mealtimes. We saw some care staff provided support that was rushed and did not give people their full attention during this time. People’s dignity was not always respected. There were several incidents across the day when a toilet door in a public area was left wide open, whilst the toilet was in use.

People were not always given a choice of suitable food and drink to meet nutritional needs and their choices were limited. Action was not always taken to identify a dietary plan for people where there were concerns with their weight loss, so that people were helped to eat sufficient amounts.

Some people living at the home raised concerns about the number of care staff available to meet people’s needs. There was no evidence that the number and skill mix of care staff was kept under review. On the day of the inspection, care staffing levels did not provide adequate support at mealtimes.

The general quality and accuracy of care plans and records needed to improve. It was sometimes difficult to check that care provided continued to meet people's needs.

People living at the home told us about the activities they had undertaken. They said that they enjoyed the knitting circle, and making cards at Easter and Christmas. We were told by staff that people using the service had programmed activities. These included bingo, arts and crafts, candle making, knitting circle and a music and film session.

People living at the home told us they are listened to, and that staff involved them in the day to day activities and running of the home.

Comments received included, “I’m happy with the staff; they look after us, and make sure we have had something to eat”. “They care for my relative very well”, “my relative has been in this home for a while now, and I know that the staff look after her”. “It’s not like home, but it’s not too bad here”.

Staff told us they were aware of the importance of keeping vulnerable people safe.

The relatives of a person who was celebrating their birthday told us that they had not had a problem with staff, they had always found staff to be polite, co-operative and caring. They also told us that the cook had made their relative a lovely birthday cake.