This inspection took place on 25 April 2017 and was unannounced. The Limes Residential Home is a care home registered to provide accommodation with personal care for up to 32 people, including people living with a cognitive impairment. There were 27 people living in the home when we inspected.

There was a registered manager in place at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

People and their families told us they felt the home was safe. Staff and the management team had received safeguarding training and were able to demonstrate an understanding of the provider’s safeguarding policy and explain the action they would take if they identified any concerns.

The risks relating to people’s health and welfare were assessed and these were recorded along with actions identified to reduce those risks while promoting choice and independence.

There were systems in place to monitor the quality of the care provided and the safety of the environment. Accidents and incidents were monitored and analysed and remedial actions identified to reduce the risk of reoccurrence.

There were suitable systems in place to ensure the safe storage and administration of medicines. Medicines were administered by staff who had received appropriate training and assessments. Healthcare professionals, such as chiropodists, opticians, GPs and dentists were involved in people’s care when necessary.

People were supported by staff who had received an induction into the home and appropriate training, professional development and supervision to enable them to meet people’s individual needs. There were enough staff to meet people’s needs and to enable them to engage with people in a relaxed and unhurried manner.

Staff sought verbal consent from people before providing care and followed legislation designed to protect people’s rights.

People were supported to have enough to eat and drink. Mealtimes were a social event and staff supported people, when necessary in a patient and friendly manner while promoting their independence.

Staff developed caring and positive relationships with people and were sensitive to their individual choices and treated them with dignity and respect. People were encouraged to maintain relationships that were important to them.

People were provided with appropriate mental and physical stimulation and had access to activities that were important to them. Staff were knowledgeable about people’s right to choose the types of activities they liked to do, and respected their choice.

There was an opportunity for people and their families to become involved in developing the service and they were encouraged to provide feedback on the service both informally and formally.

People and relatives were able to complain or raise issues on a formal and informal basis with the registered manager and were confident these would be resolved. This contributed to an open culture within the home. Visitors were welcomed and there were good working relationships with external professionals.

People and their families told us they felt the home was well-led and were positive about the registered manager who understood the responsibilities of their role.

This inspection took place on 2 March 2016 and was unannounced. The home provides accommodation for up to 32 older people with personal care needs. There were 22 older people living at The Limes when we visited, some of whom had a physical disability or were living with dementia.

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. When we completed this inspection the registered manager was not working at The Limes. The provider had arranged for an alternative manager who had been managing the service since December 2015.

After comprehensive inspections in July and November 2015, we identified that improvements were required to ensure people received a safe, well-led, effective service which was caring and responsive to their needs. We made compliance actions and issued three warning notices to the provider and registered manager requiring them to make improvements. We rated the service as inadequate and placed it in Special Measures. The provider then sent us action plans stating what they would do to meet the legal requirements in relation to improving their service. At this inspection we found improvements had been made. These need time to become sustained and fully embedded in practice, but we have taken the service out of Special Measures.

Environmental risks were not managed appropriately. All necessary action had not been taken to ensure deficiencies identified by a fire risk assessment had been completed. Arrangements were in place to check the temperature of hot water; however, the records showed these were frequently too high, placing people at risk of scalding.

People and relatives were positive about the service they received. They praised the staff and care provided. People felt safe at the home. Care staff knew how to prevent, identify and report abuse.

People received personalised care from staff who understood their needs and they were supported to make choices. Care plans provided comprehensive information about how people wished to be cared for and staff were aware of people’s individual care needs. Most individual risks to people were managed effectively, although some concerns were identified about the management of pressure injuries.

People had access to healthcare services and were referred to doctors and specialists when needed. Suitable arrangements were in place for managing medicines, although use by dates were not recorded for prescribed topical creams.

Staff followed legislation designed to protect people’s rights and freedom to help make sure decisions were only taken in the best interests of people.

People were positive about meals and the support they received to ensure they had a nutritious diet in sociable surroundings.

Plans were in place to deal with foreseeable emergencies and staff had received training to manage such situations safely.

The provider had identified a need for additional staff and were taking action to provide this. Safe recruitment practices were followed. Staff provided effective care; they were suitably trained and appropriately supported in their role.

Staff treated people with kindness and compassion and formed caring relationships with them and their relatives. Staff protected people’s privacy, promoted their independence and involved them in planning the care and support they received.

There was an open and transparent culture. The provider encouraged staff feedback and visitors were welcomed. Complaints, when received, were investigated and responded to. Quality assurance processes were in place to assess key aspects of the service. Where these had identified a need for improvement action had or was being taken.

We found one breac

We carried out a focused inspection on 19 November 2015 to check whether The Limes has taken action to meet the requirements of two warning notices we issued on 24 August 2015. This report only covers our findings in relation to these topics.

We undertook an unannounced comprehensive inspection at The Limes on 7 and 10 July 2015 at which breaches of regulations were found. You can read the report from our lastcomprehensive inspection, by selecting the 'all reports' link for ‘The Limes Residential Home’ on our website at www.cqc.org.uk’.

The Limes Residential Home is registered to provide accommodation for persons requiring nursing or personal care. The Limes is a residential care home for up to 32 people. At the time of our inspection 27 people were living at The Limes some of whom had physical disabilities or were living with dementia.

The home had a registered manager at the time of our 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.

At The Limes care is provided on three floors. A passenger lift is available for people to access the rooms on the upper floors. A large dining room and three lounges are located on the ground floor. The garden was well maintained and people had access to the outside areas.

Care provided at The Limes was not always safe. Risks to people’s health and wellbeing were not always assessed effectively and action was not always taken to reduce those risks. When people’s needs and risks increased, assessments were not always updated. Key information in relation to risks to people’s health and wellbeing was not recorded consistently and communicated in an effective way to all relevant staff.

Some aspects of medicines management were not safe. Systems were in place to ensure people received their medicines at the appropriate time. Staff administered medicines in a discreet and caring manner and recorded what was administered accurately.

People felt safe with care staff. Staff were aware of the signs that might indicate abuse and knew what to do to if they had concerns. They were confident about reporting abuse and demonstrated personal accountability in relation to people’s safety. Safeguarding concerns were reported appropriately and investigated thoroughly.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.

The inspection was carried out on 7 and 10 July 2015 and was unannounced. This was our first inspection since the provider was registered with CQC to provide a regulated activity.

The Limes Residential Home is registered to provide accommodation for persons requiring nursing or personal care for a maximum of 32 people. At the time of our inspection 28 people were living at The Limes Residential Home some of whom have physical disabilities or are living with dementia.

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 Limes care is provided on three floors. A lift is available for people to access the rooms on the upper floors. A large dining room and three lounges are located on the ground floor. The garden was well maintained and people had access to the outside areas.

Care provided at The Limes was not safe. Medicines were not managed safely and safeguarding incidents were not reported and investigated appropriately. Risks to people’s health were not always assessed and action taken to reduce the risks. At times there were insufficient staff available to ensure people’s needs were met in a safe way.

Whilst staff treated people with kindness, they were not always respectful when addressing people or recording information about people’s needs. Staff respected people’s privacy but were not always careful to protect their dignity. The provider did not ensure that the appropriate process was followed to protect people’s rights when people lacked mental capacity to make some decisions.

Staff practice was not monitored effectively and some staff were not up to date with training necessary to meet people’s needs. People’s care plans were not always up to date. Care plan reviews were not always effective which meant people’s most current needs were not always documented.

Staff were aware of the signs of possible abuse. The registered manager did not always report incidents that were notifiable to CQC or to the local authority safeguarding team. Some staff were unaware they were using unlawful restraint on people whose behaviour placed themselves and others at risk.

Checks on the suitability of staff wishing to work in the home were carried out. Complaints were responded to however the policy was not detailed enough to ensure people knew how to escalate their complaint if they wanted to.

People enjoyed the food which was plentiful and presented in an appealing way. People had a choice of main meal and several choices of dessert. People’s specific dietary needs were met. A pleasant and calm atmosphere was present in the home and staff chatted with people in a relaxed manner.

Some people did not have access to meaningful activities. We have made a recommendation to the provider about this. The environment had been adapted to assist people who were living with a diagnosis of dementia and outside areas were accessible and well-maintained.

Staff responded to calls bells in a timely manner and people said staff were attentive to their needs. Staff took care to promote people’s independence and provided assistance only where this was required.

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