The Limes Retirement Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked at all the quality statements for Effective at this assessment. We found the service was not effective. There has been a decline in the service since the last inspection. During our assessment of this key question, we found 2 breaches of regulation relating to consent and person-centred care. Further details of our concerns can be found in the evidence category findings below. Pre-admission assessments were not always carried out to ensure the service was suitable to meet the needs of the individual. Assessments completed did not translate into person-centred, effective care plans. This included a failure to assess the impact of specific health conditions, dementia related needs and the need for social and emotional support. People were not adequately supported during mealtimes to ensure they were eating and drinking enough. Management and staff did not understand or carry out their responsibilities under the Mental Capacity Act 2005 when supporting people who may lack capacity to make specific decisions. The complexity of relationships and physical contact was not acknowledged for people with dementia and proper processes had not been followed to assess individuals understanding, retention, weighing up and communicating of information related to this situation.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People could not be confident their individual needs had been appropriately assessed and fully understood, or that the service could meet them. Assessments of need did not consider the full range of people’s diverse needs and physical health. Wellbeing and communication needs were not sufficiently assessed and planned for. Care and support provided by staff to people was inconsistent and not based on an agreed plan to meet their specific needs. This placed people at risk of receiving inappropriate and unsafe care and support.

The registered manager told us they had not carried out their own assessment of people’s needs when moving into the service. They confirmed they had relied on assessments carried out by other professionals, and the hospital discharge letters. They could not explain how they had ensured the service was suitable to meet the needs of 3 people who had recently been admitted. Staff told us they did not regularly read and follow care plans and were not involved in the care planning process.

Care records lacked detail on people’s strengths, the nature and level of support they needed to meet their needs and to support their independence as much as possible. Whilst care plans were reviewed, they did not show that people’s needs were regularly re-assessed, and plans revised accordingly to accurately reflect their changing needs and support.

People living at The Limes were at different stages of their dementia ranging from early onset to advanced stages. There was no plan about how the service kept up to date and developed positively in this area to ensure the care provided was right and reflected best practice. For example, sexual safety, engagement, stimulation and occupation, communication and eating and drinking. People’s nutrition and hydration needs were not consistently met.

Staff had a limited understanding of how dementia affected people in their day to day living. Appropriate strategies were not in place and staff did not know how to promote and keep for as long as possible, individual's interests and independence. Staff, including the cook told us they had not received training on how to support people who had difficulties swallowing (dysphagia) and at risk of choking. Where the speech and language therapist (SaLT) had assessed people as needing specific food texture and consistency the cook and staff could not explain how to prepare foods and fluids in line with the international dysphagia diet standardisation initiative (IDDSI) best practice principles. IDDSI is a global standardised way of describing foods and drinks that are safest for people with feeding, chewing or swallowing problems. One staff member said, “There a couple of people who have pureed diets, but I have never heard of IDDSI.”

The provider did not have a robust system to ensure the cook and staff were informed correctly of people’s nutrition and hydration needs. Despite people prescribed a Level 4 (pureed) diet and Level 6 (soft and bite sized) information in the kitchen and care records about their dietary needs was either incorrect or contradictory. The providers nutritional care policy last reviewed in May 2024 lacked guidance for staff about risks associated with dysphagia, choking risk or poor oral health, and omitted the IDDSI guidelines. There were not enough staff to support and interact with people left to eat independently, and therefore they did not receive the encouragement or practical help they needed to eat more.

People’s transition between services was not managed well. Information was not routinely shared between staff and services to ensure people received joined up and continued care and accessed healthcare services when needed. One relative told us, “My [Family member] missed a cataract appointment in March this year, as staff had not told me. Staff handed me 3 letters from the hospital when I arrived here one day, they should have opened them and told me.”

Staff described a lack of information sharing which affected people’s continuity of care. For example, they were unaware of a person’s healthcare needs 2 days following their admission to the service which placed the person at risk of unsafe care. Staff did not have access to the information they needed to deliver responsive, safe and effective care.

We received mixed feedback from partners about working relationships. Some found management and staff to not be very cooperative. However, the local GP practice told us they had a very good working relationship with the service.

Referrals to other health professionals, was inconsistent. Referrals had been made to the GP, district nurses, physiotherapist and occupational therapists, but no referral had been made to dietitians where people had lost weight. Recommendations and guidance from healthcare professionals was not always translated into people’s care plans and monitoring records.

Risks to people’s health and wellbeing were not always identified and managed early enough to prevent deterioration. Whilst the GP practice told us the service referred promptly for people who had sustained injuries from falling, we found the service had not considered how they could reduce the number of falls people were having.

The provider told us it took 2 months to find a chiropodist to replace the 1 that had retired, and they were having trouble in finding a dentist to visit the service.

Processes were not in place to focus on identifying risks to people’s health and wellbeing early on, or how to support people to prevent deterioration. Whilst people’s weights were measured there was no overall analysis to identify unwanted weight loss and manage appropriately. We found 11 people had lost weight between December 2023 and June 2024, with no intervention from health professionals.

People were not supported to promote their wellbeing and did not consistently experience positive outcomes. There was an absence of inclusive activity. People sat for very long periods of time; lack of mobility causes stiffness and poor balance reducing confidence and independence and increases the risk of falls. One person had experienced 8 falls in 8 weeks because there were times when they were unable to take their weight when transferring, causing them to fall. We saw this person sat on a hard chair from 4pm until they were taken to bed at 9:50pm. Despite the person being stiff and unsteady when they got up, their knees buckling beneath them, one staff member was pulling them, and another staff member was pushing from behind. The person was unsteady and was struggling to mobilise, so we told the staff to use the wheelchair nearby, the person was relieved to sit in it. Another person was having difficulty trying to push themselves up to stand, they said, “I’ve been here too long, nobody seems bothered.” Other people were walking around searching becoming agitated and emotionally distressed.

There was no effective oversight by the provider and management to identify and monitor changes in people’s needs such as weight loss, mobility, continence needs or emotional needs. Appropriate strategies were not in place and staff did not know how to promote and keep for as long as possible, individual's interests and independence.

Where people needed support with their mental or emotional health, there was limited information within their care plans about triggers or de-escalation techniques to support staff in maintaining people's wellbeing. There was a lack of effective processes for monitoring people’s care, treatment and outcomes to ensure continuous improvements to their quality of life. This included daily care records, which were task-led, they did not give any information about how the person's day was spent, nor did they give any reference to personalised care, promoting independence or their wellbeing.

People’s capacity and ability to consent was not always taken into account. People did not always receive information about care and support in a way they could understand or have proper support and time to make decisions.

Management and staff did not have a good working knowledge of the principles of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty safeguards (DOLs). Two people living with dementia had developed a relationship, currently expressing less intimate affection such as holding hands, touching and kissing. Whilst there are wellbeing and human rights elements to the companionship the registered manager had not recognised and acknowledged the possibility of intimacy developing further and their capacity to engage in a sexual act had not been assessed. If one or both people were assessed to lack the capacity to engage in sexual relations, a best interest decision would be needed to prevent sexual activity and keep them safe.

Electronic care plans held generalised statements about people's capacity and were not specific to the individual. Some were contradictory and did not reflect how a person might express themselves or show agreement, preference or choice.