We commenced an unannounced comprehensive inspection on 13 March 2018. We also visited the home unannounced at 04:10 on the morning of 15 March 2018 and completed the inspection on 19 March 2018.

This was the first inspection since the service was registered in March 2018 under a new provider’s registration. The home had been in operation for a number of years previously.

The Lime Trees 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 Lime Trees is registered to accommodate up to 20 people and does not provide nursing care. On the dates of the inspection, there were 17 people living at the home.

The Lime Trees is set out over three floors with lift access. The building is both an older Victorian style and a new purpose built unit. There was a small garden at the back of the home which was mainly used as a smoking area.

There was a registered manager in place. 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 safeguarded from abuse and neglect. People were sleeping in soiled and dirty bedding. People were showered in view of communal areas and as a result were exposed naked to other people, staff and visitors. Safeguarding incidents were not always recognised or reported to the local safeguarding authority.

People were deprived of their liberty without having appropriate legal safeguards in place.

People were not treated with dignity and respect. The majority of people we spoke with during the inspection told us of their unhappiness living at the Lime Trees. Most people told us that they were not respected and exercised little choice in how they lived their lives. We observed instances of staff and the registered manager treating people in a disrespectful manner.

The home was unclean. The premises and equipment within the home was not maintained to a safe standard. Strong offensive odours were detected throughout the home. Staff were not always adhering to basic infection control procedures.

There were not always enough staff deployed in the service to consistently meet people's needs. Care staff were deployed to non-care tasks such as cooking, laundry and cleaning. Staff were not able to respond to people’s needs in a prompt manner.

The provider did not always adhere to the Mental Capacity Act 2005.

People were not always receiving care from staff who were competent, skilled and experienced. The provider did not keep appropriate records of training.

The provider did not ensure safe staff recruitment. Not all staff had undergone appropriate recruitment checks prior to working with vulnerable people as an employment history or references had not been obtained. The provider had not carried out their own criminal records checks on some staff.

Care plans were not in place for all people receiving support. People's preferences were not appropriately recorded. Care plan reviews did not evidence people’s involvement in planning their care.

People’s health, safety and wellbeing was at risk because the provider failed to adequately assess risk and did not manage medicines safely.

Overall governance of the service was ineffective. The registered manager carried out regular monthly quality checks. Where these checks had identified concerns with aspects of care delivery, improvements had not been made.

Staff received regular supervision from the registered manager.

We received mixed feedback from people regarding the food choices on offer. Where people required assistance, we observed staff patiently provide assista

This inspection took place on 14 September 2018 and was unannounced.

At our last inspection on 13, 15 and 19 March 2018, we found breaches of regulations relating to person centred care (Regulation 9), treating people with dignity and respect (Regulation 10), consent to care (Regulation 11), safe care and treatment (Regulation 12), safeguarding people from abuse (Regulation 13), premises and equipment (Regulation 15), good governance (Regulation 17), staffing (Regulation 18) and fit and proper persons (Regulation 19).

The service was rated inadequate and placed into special measures following the March 2018 inspection. Special measures are designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Its purpose is to ensure that inadequate care significantly improves and provides a clear timeframe within which the provider must improve the quality of care they provide. When a provider is placed into special measures, the CQC will re-inspect within six months.

A Notice of Decision was served on the registered provider on 23 March 2018 to impose a condition to restrict the admission of new people without authorisation from CQC. Full information about additional CQC regulatory responses to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The Lime Trees 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 Lime Trees is registered to accommodate up to 20 people and does not provide nursing care. At the time of this inspection, there was one person living at the home. This meant that although we could carry out an inspection we could not fully rate the quality of the service as we had insufficient evidence on which to do so.

The registered manager had left the service three weeks before the inspection, a new manager was in place who had started the process of applying to be registered. 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 this inspection, we found that the provider had achieved compliance with seven of the nine regulations previously identified as breached during the comprehensive inspection in March 2018. However, we found improvement was still needed with regards to safe staff recruitment and equipment being fit for purpose. This meant the provider was still in breach of two regulations.

We identified concerns with how staff were recruited. While checks such as criminal records checks (DBS) and identification checks were completed, the provider’s referencing process was not sufficiently robust at ensuring staff were suitable to work with vulnerable people.

In two bedrooms, we found old odorous urine stains on mattresses from when the bedrooms were last occupied. We identified additional environmental concerns such as a water leak in one room and some kitchen equipment in a poor state of repair. Some of these concerns were addressed either during the inspection or shortly afterwards.

Increased quality assurance processes were in place which helped the service identify areas for improvement. New quality monitoring checks included weekly medicines audits, dining experience and cleanliness checks. However, we could not be assured that the quality monitoring systems in place were robust as we identified repeated areas of concern at this inspection.

Staff had received training around medicines management and had their competencies assessed. The person living at the service was receiving their medicines safely and processes had been implemented to ensure medicines were monitored effectively.

Staffing levels were appropriate for the level of occupancy at the service.

No safeguarding concerns were identified during this inspection. Staff had received training on safeguarding and knew where they could report concerns.

The provider had implemented procedures to ensure compliance with the Mental Capacity Act 2005.

The person living at the service was happy with the care they received and complimentary of care staff and the management team.

The person had a care plan and risk assessment in place which identified their care needs, risks associated with their care and provided guidance to care staff on how to work with the person.

Staff received training in areas such as fire safety, first aid, infection control and basic life support. They received regular supervisions and an annual appraisal. This helped ensure they had the knowledge and skills to provide effective care.

At this inspection, we identified repeated breaches of regulations 15 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.