The Limes Retirement Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked at all the quality statements for Safe at this assessment. We found the service was not safe. There has been a decline in the service since the last inspection. During our assessment of this key question, we found concerns about unsafe care and treatment, the premises, safeguarding and staff training and recruitment which resulted in 5 breaches of Regulations. Further details of our concerns can be found in the evidence category findings below. Systems were not in place to protect people from avoidable harm or abuse and keep them safe. There was a lack of recognition and understanding of risk, and a lack of robust assessments and controls in place to protect people. There were not enough suitable staff with the right competencies, knowledge, and attitude needed to keep people safe and meet their needs. Staffing levels were not based on the type and level of support each person needed throughout the day, and night. Staff were not deployed in a way that was consistent with person centred care. People did not receive meaningful occupation and stimulation that promoted well-being. Staff were not recruited safely. Staff did not receive structured and planned support and development to enable them to meet people’s needs safely and effectively and poor performance was not addressed.

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.

The service did not have a proactive culture of safety and learning. Lessons were not learned from incidents or complaints and therefore changes were not implemented to improve staff understanding and delivery of care, and to keep people safe.

Leaders and staff did not have oversight of incidents at the service. People’s records showed a significant high number of incidents and falls. The registered manager was not aware there had been 52 recorded falls in 6 weeks. There were more falls and incidents which staff had not reported or recorded. Staff did not recognise the risk to people or raise concerns properly such as repeated falls, or incidents related to sexual safety and altercations.

There were no systems in place to effectively and proactively identify and manage risks to people before safety events happened. Falls and incidents were not investigated to see if there were any contributing factors, trends and/or themes and no action had been taken to reduce them. This meant leaders were unaware of current and escalating risks to people’s health and welfare. Incidents were not used as an opportunity to put things right, learn and improve outcomes for people; instead, incidents continued to reoccur with no effective mitigation in place. There was no means in which staff could learn lessons from safety events to reduce the risk of reoccurrence. This placed people at continued risk of harm, including from potentially avoidable events.

People’s care and support was not planned for and organised with them, together with partners, and therefore a joined-up approach to safety and continuity of care was not taken. Some people were accepted for admission to The Limes whose needs could not be met. For example, the suitability of the environment was not considered in relation to a person’s mobility needs. Their wheelchair and moving equipment were unable to pass through doorways and corridors, resulting in the individual being unable to take a bath or shower.

The registered manager told us they had not carried out their own assessment of people’s needs when they were admitted to the service from hospital. We found people admitted from hospital were not receiving joined up care. Information from hospital discharge letters had not been transferred into a working plan of care to enable staff to deliver continuity of care in a safe way. For example, following a recent admission to The Limes, staff were unaware of the risks to a person’s health and welfare. Follow up referrals had not been made and the right care and support was not being provided to meet their needs.

There were no effective systems in place to proactively consider, assess and manage risks to people when moving between services, for example from hospital into the home.

People told us they did not always feel safe. Comments included, “My only concern is that 1 person keeps coming in my room, they wander all over the place, and do not know where they are,” and “[Person] exposes themselves all the time, urinating, shouting, hitting out and upsetting people.” People were not safeguarded from the risk of sexualised behaviours. The risk posed to the person and others from sexual safety incidents had not been assessed and there were no recorded support planning arrangements in place to minimise the risk and keep people safe.

The provider did not recognise or understand the wider aspects of safeguarding people from risk or harm. Management and staff had a poor understanding of capacity, consent and sexual relations or how to protect people from incidents triggered by sexual disinhibition or other features of a person’s mental health or dementia. The registered manager told us they were not aware of these incidents and therefore confirmed they had not reported concerns to the local authority safeguarding team. Staff told us they had not received any training in relation to supporting people whilst expressing their emotions or distress through behaviour.

We saw people expressing their emotions in a way which placed them and others at risk, including physical assault, exposure, urinating, pushing, hitting and kissing. We had concerns related to sexual safety and we raised an organisational safeguarding alert about widespread poor practice.

Systems and processes were not in place and working effectively to safeguard people from abuse. There was no effective oversight of incidents, accidents and safeguarding concerns which meant they were not reported and investigated in a transparent way to reduce risk of reoccurrence.

People were not protected from harm. People did not have detailed and personalised risk assessments and management plans to guide staff about risks to their health and welfare and how to minimise those risks.

We shared concerns with the provider and registered manager about the poor quality of risk assessments and associated plans of care. We were told that an external person came in to write risk assessments and care plans for people. The person or those primarily caring for people were not involved in the planning of their care and staff told us they rarely looked at care plans. Not all staff knew where the fire safety folder was kept. This held people’s personal and evacuation (PEEPs) which contained information needed to ensure a safe and prompt evacuation.

Observations of some staff moving and aiding people showed poor practice, such as underarm and drag lifts, placing the person at risk of injury.

Risk assessments did not fully assess and mitigate risks in relation to supporting people to move, eat and drink safely and catheter care. There were no clear plans of care and best practice approaches to support people and manage risk in relation to moving and handling, falls, dementia needs, communication and sexual safety. Reviews did not show if measures in place were working or if further measures were needed to minimise risks to people’s health and welfare. Monitoring systems were not effective. People’s food and fluid intake was not always recorded for effective monitoring to ensure they were eating and drinking properly. Fluid output for people with indwelling catheters was also not recorded and checked. If fluid output was reduced this may be a sign of potential blockage and retention. The provider did not have an effective system for ensuring people’s PEEPs were correct, current or in place. Some PEEPs did not accurately reflect people’s needs and current mobility status. PEEPs in the fire safety folder had not been updated and held PEEPs for people no longer at the service. There were no PEEPs in place for people recently admitted. This could cause confusion and delay an emergency evacuation.

People were not cared for in a safe environment. The service did not meet the needs of people living with dementia in relation to design and decoration, lighting, signage, sensory needs points of interest and assistive living technology. Frail and immobile people were living in rooms on the first and ground floor, with poor accessibility, uneven floors and limited space which were unsuitable for those who used walking frames, wheelchairs or other moving equipment. One person asked us to look and feel their bedroom floor, it was uneven with a gradient, they had previously lost their balance and fallen. They told us, “I have had 2 strokes, use a stick and I feel unsafe on this floor.”

The restricted width of the stairs due to the stair-lifts had not been considered for people with poor mobility and or dementia related needs. If an emergency evacuation was needed it was not clear how these people were to be supported to evacuate safely. A wooden gate had been wedged at the bottom of the external metal escape stairs which would hinder a quick escape route. One staff member told us they couldn’t remember when they last had fire safety training or a fire drill and other than going to the assembly point was not aware of any evacuation procedure, they said, “We wouldn’t be able to get them out anyway from upstairs as there is no equipment.”

The environment looked tired and was poorly maintained, particularly in the older part of the building and the garden areas. Corridors were dark, and there was an absence of handrails in parts of the premises to help support people to mobilise. Access to the first floor was by narrow stairs impeded by a stair lift that overlapped the narrow landing causing a potential trip hazard. One person showed us their difficulty in manoeuvring their walking frame and walking stick and accessing the stair lift. We found a build-up of items and debris behind the washing machines and dryers, around wiring and electric plug sockets. This was a potential fire risk. We brought this to the attention of the provider, who has since cleared the area. Call bells in the communal areas for people to call for help were not accessible which meant they were reliant on staff to be visible for support. Throughout our visits to the service, we saw people putting themselves and others at risk whilst staff were not in attendance and other people had to summon aid to intervene.

There were no effective arrangements in place to check the safety and upkeep of the premises. The fire risk assessment carried out in April 2024 by the registered manager had not found any of the concerns we raised. We referred our concerns to the local fire and rescue service.

Some people and relatives told us they thought there were enough staff at The Limes. However, we found there were not enough suitably qualified and skilled staff deployed to meet people’s needs and keep them safe. There was not enough staff to ensure people were always supervised to reduce the high number of unwitnessed falls. People were not provided with adequate nutritional support, stimulation and meaningful interaction. Staff were not sufficiently recruited, inducted, trained or supported in their role to meet people’s needs safely, effectively and responsively.

The provider and registered manager could not show how they ensured there was enough skilled staff to meet people’s needs. They did not have a clear overview of the complexity of people’s current needs and levels of dependency. The provider told us staffing levels had remained the same for years. Staff told us there was not enough staff to meet people’s needs and complete other duties, especially at night. Comments included, “There has always only been 2 staff at night, and this has never increased even though people at the service now have more complex needs,” and “I think they need 3 staff on nights, it gets very busy. We are expected to attend to people’s personal care, as well as answer bells, do laundry, peel vegetables, prepare breakfast, and check on people in all of the cottages.” Staff were well intentioned, however care delivered was instinctive, which was not based on learning and best practice. Conversations with staff and their interactions with people showed skills were lacking in person centred care, engaging with people in purposeful activity and responding effectively to the wider aspects of people's dementia related needs. These included communication, distress and unsettled behaviours, sexual safety, person centred care and modified diets. Staff were using a lifting cushion to get people up off the floor without having the relevant training to use the equipment safely. This placed people at the risk of harm. Staff told us they had not received fire evacuation training and would not know how to get people out in an emergency.

During our visits we saw there were not enough competent staff to provide the necessary support people needed to reduce the risk of harm and promote wellbeing. There was an absence of inclusive activity throughout the day. People were not supported to eat well and were not provided with the encouragement and practical help they needed to eat more. People were left unsupervised and left to their own devices for long periods of time resulting in altercations between people who were agitated and distressed. Other people were left for long periods of time without any movement or interaction, and were found on the floor, having fallen. Staff showed a poor understanding of dementia and how it affected people in their day to day lives. We informed the local safeguarding team of our concerns

The provider did not ensure staffing levels, competency and training were adequate to meet the needs of people using the service. Learning and development was not managed and planned in a way that ensured staff had the opportunity to build on their knowledge base and develop their skills to carry out their roles and meet people’s specific needs. We found significant shortfalls in staff training, including essential training in safeguarding, fire safety and dysphagia. The providers website stated they provided specialist support for people with dementia, yet staff lacked training in dementia and associated behaviours to make them specialist in this area. Staff told us they felt supported, but records showed formal appraisal and supervision had been lacking. Where supervisions had taken place, records were poorly completed. Recruitment processes were not robust to ensure staff were safely recruited and induction processes were poor. Staff had no knowledge of the Care Certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected for specific job roles in the health and social care sector, and associated assessment of competence.

People were not protected from the risk of infection. We observed people living in an unclean environment which adversely effected their quality of life at the service.

Staff were not familiar with the Food Standards Agency, Safer Food Better Business (SFFB) guidance. The SFBB is a food safety management pack for small residential care homes that prepare and cook food for people in their care. Opening and closing checks are tasks which needed to be completed daily to ensure the kitchen facilities and equipment are clean and hygienic Whilst staff were signing off food standard safety checks they could not tell us what the checks were.

We saw the kitchen, including equipment and utensils were not clean. The floor was stained and covered in debris. The laundry had a dirty and clean area, but they were not being used effectively to safely segregate soiled and clean washing. Clean washing was hanging in the dirty area posing a risk of cross infection. Paint was peeling off the walls in people’s rooms and in communal areas, radiators were rusting, and flooring in 2 people’s en-suites was lifting, with gaps around the skirting and door thresholds, creating a reservoir for harbouring bacteria. People’s equipment, such as commodes were seen to be rusting. Rusty objects are a contributor to health acquired infections (HAIs) because it does not allow for effective cleaning. Personal protective equipment (PPE) such as gloves and aprons were left draped over toilet cisterns or in baths causing them to become contaminated prior to use. Although plastic wipeable storage was available it was not being used. People’s continence needs were not effectively managed and flooring in their rooms and communal areas were stained and contributed to the odour throughout the home.

The provider did not have robust systems in place to effectively identify the risk of infection. Infection prevention and control (IPC) measures needed to improve to ensure the service was clean and hygienic in line with current and relevant national guidance. Systems were not in place to ensure staff were following the department of health (DOH) infection control guidelines for the safe management of people’s clothes and linens.

Staff took time to explain and provide reassurance to people when administering medicines, however we found people were not receiving their medicines as prescribed by their GP. This had the potential to affect people’s health or place them at risk of harm. New people admitted to the service did not have a care plan to guide staff on potential risks from their prescribed medicines, such as anticoagulant (blood thinning) medicines used to prevent blood clots and prevent strokes. One person recently admitted to the service fell 2 days after admission, placing them at risk of extensive bleeding, however no medical check-up was sought as recommended in their hospital discharge letter.

Although staff told us they had received medicines training, they had failed to recognise and report out of date medicines and understand the importance of ensuring people received their medicines on time. For example, administration of time specific medicines to treat and prevent osteoporosis and thyroid hormone deficiency were being administered together against pharmaceutical advice and not at the right times.

The providers medicines policy was not comprehensive, and needed updating to ensure medicines were being managed in line with legislation, and current national guidance. Medicine administration records (MARs) were poorly completed. Charts for medicine patches to treat mild, moderate, and severe dementia, and pain were either not in place, or not completed fully to ensure they were being applied correctly and checked daily. There were significant gaps in recording on medicines charts for administering creams. We found creams had expired and were being applied, where they were no longer prescribed for the person. There were no ‘as required’ (PRN) protocols in place to support staff to know when to administer these medicines. For example, where people required variable does of medicines, such as morphine there was no guidance available to staff to indicate what type of pain this was to be used for or what dose to give, and when. Medicines audits carried out by the registered manager were not picking up these failings.