We inspected Limetree Care Centre on 2nd, 3rd and 4th July 2018. The inspection was unannounced. This meant that the provider and staff did not know we were coming.

Limetree Care Centre is a nursing home providing care and support over three floors for up to 92 older people, some of whom were living with dementia. 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.

At the previous inspection in April 2017 the home was rated "Good" in all areas. However, we received information of concern from relatives and other agencies that the service had begun to show signs of poor management, leadership and governance and was not always able to ensure delivery of high-quality, person-centred care for people, which prompted this inspection. We found that on this inspection the service did not meet some of the required standards relating to safety, providing effective and responsive care and in the management and leadership of the service.

The service did not have a registered manager in post at the time of the inspection. A new manager had been recruited and was going through the process of registering with the Commission. 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.

There were not always sufficient numbers of suitably qualified and experienced staff to provide the necessary care and treatment to people.

People's health and nutrition were not always monitored effectively. Fluid and nutrition charts were of variable quality, as were records of people's weight changes.

People did not always receive personalised care that was responsive to their needs. Care plans did not fully reflect people's interests and background. The quality of and frequency of activities was variable and staff did not spend much time in meaningful interaction with people.

The service was not always well-led by a consistently good management team. The service had a high number of incidents and accidents and was engaged in an improvement programme with the local authority. This, together with the areas of concern identified during this inspection meant that the service was not always able to ensure delivery of high-quality, person-centred care for people.

The service carried out suitable pre-employment checks to ensure safe care for people.

Staff knew their responsibilities to protect people from potential harm and abuse and how to report this.

There was a garden which people and relatives commented positively about, and which we saw was being well used on the hot summer day.

Staff we spoke with confirmed that they had attended Mental Capacity Act (MCA) training and were able to tell us about the principles of the MCA, acting in people’s best interests and how they applied these in their work with people.

People at the home were treated in a kind and compassionate manner which respected their privacy and afforded them dignity. Relatives spoke positively about the staff. Relatives also commented that they could visit at any time and that they could trust the staff.

Staff addressed people according to people’s wishes. We observed staff treating people with kindness and compassion, speaking quietly and gently to people and it was clear that staff knew people well. We saw notices on doors when personal care was being given, which ensured people’s privacy.

The service had a complaints policy and procedure. The policy included timescales for responding to complaints and details of how people could escalate their complaint if they were not satisfied with the initial response from the service. People us

Limetree Care Centre is a care home providing care and support to up to 92 older people living with dementia. 91 people were living in the service at the time of our inspection.

At our last inspection in January 2015 the service was rated as 'Good’. At this inspection we found the service remained Good.

The service had a registered manager at the time of the inspection. 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 continued to be kept safe by staff who were trained to protect them from abuse. Staff reduced people’s risks of avoidable harm by assessing their risks and developing plans to mitigate them. Staff were deployed in sufficient numbers to ensure people’s safety and the provider used appropriate vetting and selection methods to recruit staff. People received their medicines safely and the service good infection control practices were in evidence.

The service continued to be effective. Staff were trained, knowledgeable, supervised and skilled. The service understood its legal responsibilities under the Mental Capacity Act and Deprivation of Liberties Safeguards and supported people in accordance with them. People ate well and their nutrition and hydration were monitored. People were supported to stay healthy and were supported to access healthcare services whenever necessary.

People and relatives told us that the staff continued to be kind and caring. People were supported to maintain the relationships that mattered most to them. Staff protected people’s confidentiality and supported people to maintain their independence. People were supported with tenderness and compassion at the end of their lives enabling them to die with dignity and pain free.

The provider continued to be responsive to people’s needs by embracing the use of technology. Assessments were highly detailed and resulted in referrals to healthcare professionals when specialist input was required. The provider was imaginative in the activities it offered to people and responsive in supporting people to pursue their interests. The provider actively gathered people’s views and acted decisively on the feedback they received.

The service continued to be well led. Robust audits were in place to ensure people received high quality care. The provider’s partnership working including supporting the apprenticeships of local college students and piloting research with a university hospital. Communication throughout the service was effective ensuring that all staff were fully aware and had the most up to date information to deliver people’s care. Staff commended the support they received from the registered manager.

This unannounced inspection took place on 16 January 2015. The last inspection of Limetree Care Centre took place on 17 October 2013 and it met all the regulations inspected then.

Limetree Care Centre provides accommodation and personal care to 92 older people, some of whom had dementia. There were 91 people using the service at the time of this inspection.

The service had a registered manager who had been in post since 2010. 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 service was safe. People received care and support in a safe way. Medicines were kept securely and people received their medicines as prescribed. The service identified risks to people and had appropriate management plan in place to ensure people were safe as possible. People consented to the care and support they received. The service met the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

There were sufficient staff available to meet people’s needs. People told us staff were kind and caring. We observed that people were treated with dignity and respect by the staff. People were supported to communicate their views about how they wanted to be cared for. People told us they enjoyed the choice of food that was available to them at the service and it met their nutritional needs.

Staff were trained to provide good care to the people they looked after. Staff received the support and supervision to carry out their duties effectively. Staff had had good knowledge and awareness of how to meet the needs of people with dementia.

The service had received an award in recognition of staff skills in providing care to people in the final years of life. Health professionals told us the service communicated well with them to ensure people received appropriate care and treatment.

People had their individual needs assessed and their care planned in a way that met their needs. People received care that reflected their preferences and choices. Reviews were held with people and their relatives to ensure people’s support reflected their current needs.

People were asked for their views and their feedback that was used to develop the service. The registered manager responded appropriately to complaints about the service. Regular checks on were undertaken to ensure the service was of good quality and met people’s needs.

The service was well organised and there were sufficient staff to care for people's individual needs. The relatives of the people we spoke with were happy with the home and told us that their family members were well looked after. We saw evidence of good care during the morning activities ranging from supervised breakfast with a choice of menu to the daily activities such as music, massage, crocheting and reading. The people we spoke to said they enjoyed the food and there was evidence of choice in the menu together with the facility for special requests. A person said, "They always fetch a good meal here".

We found the care planning to be systematic and detailed with evidence of people contributing to their care plans. We saw that staff dealt with an emergency and made prompt arrangements for the transfer of the person to hospital.

The staff we spoke to had access to a wide range of training and the provider monitored the access to training ensuring that statutory training was completed.

The majority of the people we spoke to were happy with the service and felt able to raise their concerns with the staff or the Manager. There was evidence that the complaints were fully investigated and that change to practice took place as a result of complaints.

People told us what it was like to live at this home and described how they were treated by 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 CQC inspector and a colleague, joined by a practicing professional and an Expert by Experience, people who have experience of using services and who can provide that perspective.

We used a number of different methods to help us understand the experiences of people using the service. A number of the people who lived at this care home had complex needs, which meant they were not always able to communicate verbally with us in a meaningful way. During the morning and at lunch we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

People told us that they were always given a choice of what to eat and that they had plenty to drink. People enjoyed mealtimes, they were able to choose to have them in own rooms or in the lounge or dining room.

People felt safe living at the home; they liked having familiar staff, who they found kind and gentle, look after them.

A person spoken with said “the staff are all nice. They are down to earth and we have a laugh as well. I watch them and think to myself- they are so patient and good!"

A relative told us that they were pleased with the care their grandparent was receiving and confirmed they had been involved in planning their care.

People told us that they found the home was a nice place to live, but that they would rather be in their own homes if their health was better. One person was in a jovial mood and enjoyed having people around, she said, "I have plenty of neighbours to talk to and am never lonely here". Another person described the flexible environment, she said "I can do what I want, when I want, how I want".

We found that the environment was calm, with people engaging with staff and in activities. Snacks and drinks were available and encouraged throughout the day, these ensured that people who become restless at mealtimes had access to finger foods throughout the day.

We felt the sense of warmth displayed from staff. They behaved in a kind and respectful manner, and took the time to explain as they assisted people with tasks.

Mealtimes were special and made as pleasurable and relaxed as possible, with all nursing and care staff present to assist people with meals.

Some people were not able to give us information about the care they received; however our observations were that their social, emotional and healthcare needs were promoted.

Relatives were generally positive about the service. One person said that his uncle had much improved since moving to the home in recent months. He said that the care and treatment has contributed to his overall well being.