The Limes Retirement Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked at 5 quality statements for Well-led at this assessment. We found the service was not Well-led. There has been a decline in the service since the last inspection. During our assessment of this key question, we found concerns about governance systems, which resulted in a breach of the legal regulations. You can find more details of our concerns in the evidence category findings below. The provider did not have safe and effective governance systems. Risk to people’s safety and welfare was not proactively and independently recognised and quality of care was not improved and or sustained. As there was no oversight or proper investigation of accidents, incidents, safeguarding, concerns and complaints the provider could not be open and transparent when things went wrong.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had no overall vision for the continuing improvement, direction and development of the service for the long term that ensured new management and staff knew what was expected of them. The provider had not actively developed and involved staff for the purpose of improving the culture and quality of the service.

The provider was not focused on continued learning and improvement. They had no development plan to drive improvement. Neither was there a shared vision, values and strategy developed in collaboration with staff and people who use the service. We observed care was delivered intuitively, not driven by best practice, in a task-based way rather than considering people's needs and wants.

Leaders did not have the knowledge and capability to ensure the service was well-led and risks well managed. Whilst staff viewed the registered manager as very supportive, we found they were inexperienced in the day-to-day management and the legal responsibilities that go with the role. There was no structured induction and support system being provided to the new registered manager for succession and development in their role. The provider and registered manager were not aware of examples of a poor culture affecting the quality of people’s care. They failed to address concerns around staff performance. For example, 2 staff had raised concerns separately about another member of staff, but actions documented for the member of staff to attend further training and attend more frequent supervisions in line with the providers policy, had not been followed up.

There was no definitive leadership or guidance for the staff team, and they were reacting to situations as they arose instead of proactively managing them. There were no systems in place to ensure staff were provided with regular support and guidance to enable them to effectively carry out their role, which meant they were not recognising or managing risks.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback from the provider, registered manager and staff did not provide assurance or evidence of robust, effective or well-embedded governance and oversight measures. Management and staff did not recognise and identify significant failings that impacted on the quality and safety of service provision. There was a heavy reliance on a weekly external consultant support, but this did not provide the oversight needed to ensure effective development, improvement and sustainability to the quality and safety of the service. Whilst older frail people are more prone to falls there was a very high level of people falling at this service. The registered manager was not aware of the significant number of falls and incidents that had been reported. They told us the external consultant looked at the incident observation reports, and they had not reported back any concerns.

The provider did not have robust and effective governance systems to proactively and continually assess the quality and safety of the service, drive improvement or find where lapses had occurred. This had led to ineffective oversight in areas such as safeguarding, staffing, culture, and accidents and incidents. Records were insufficiently detailed to address issues of concern, and there was a lack of response to act promptly in response to safety events occurring. There was no effective leadership to oversee and direct staff on each shift, and roles and responsibilities were not clearly defined. The provider did not have a system in place to review staffing levels properly and to show how they were calculated. Neither did they have an effective system in place to review people’s needs properly so that effective staffing levels were maintained. There was no workforce planning to consider how ambition, aims and goals for the service were going to be achieved. The provider did not have a pro-active approach to learning and development to prioritise staff training and develop a confident and competent workforce, ultimately improving the lives of people using the service.

Although the provider and registered manager had taken action to address issues immediately raised by us and other professionals there has been a lack of engagement with key organisations to support care provision, service development and joined up care.

It was clear from discussion with management and staff that the service had not engaged in local or national forums or development groups for best practice guidance, expertise or resources to improve the service and lead to better outcomes for people. For example, dementia care.

Partner agencies shared concerns about management and staff limited understanding of dementia care.

There was no plan about how the service kept up to date and developed positively, therefore leaders could not be sure the care provided was right and reflected best practice.

Staff and leaders did not recognise when things were going wrong and did not show a good understanding of how to make improvement happen.

The provider and management did not have robust systems in place to ensure learning happens when things go wrong. There was no record of actions and lessons learned taken forward from recent events. Staff were not supported to develop skills around improvement.