CQC report explained · a residential care home
What the CQC found at Lime Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care plans were not always complete or reviewed. Inspectors also found unsafe medicines arrangements, including a staff member without medicines training being asked to administer medicines.
- Effective?
- Requires improvement
- Mental capacity assessments were not reviewed regularly, and care plans did not always reflect people's needs, choices and goals. Support for healthy eating, sensory needs and recording healthcare follow-up also needed improvement.
- Caring?
- Good
- This key question was not included in this focused inspection, so it was not given a rating in this report. Inspectors did report that people received kind and compassionate care and that staff respected privacy and dignity.
- Responsive?
- Good
- This key question was not included in this focused inspection, so it was not given a rating in this report. Inspectors found limited opportunities for meaningful activities and limited pathways towards people's future goals.
- Well-led?
- Requires improvement
- Quality checks did not identify all the problems inspectors found, and there was no ongoing action plan. There was no registered manager in post during the inspection and oversight of the home was limited.
What inspectors found, May 2022
Lime Lodge rated Requires Improvement; inspectors found kind care but serious gaps in risk management, consent and oversight.
This was an unannounced inspection on 15 March 2022. Inspectors followed up concerns about medicines, staff training, infection control and management. They reviewed care and medicines records, staff files, audits and the building, and spoke with people, relatives, staff and health professionals.
The home was rated Requires Improvement overall. Safe, effective and well-led were all rated Requires Improvement. Inspectors found incomplete or outdated care plans and risk assessments, unsafe medicines arrangements, gaps in mental capacity reviews, limited meaningful activities and weak checks on quality and safety.
There were also positive findings. Staff were kind, understood people's needs and knew how to protect them from abuse. Recruitment checks were safe, and all staff had completed mandatory training by the inspection, although wider training needs remained.
The home had also been rated Requires Improvement at the previous inspection, published on 15 July 2021. Safe and well-led remained at this rating, while effective had fallen from Good. The home had been rated Requires Improvement for the last two consecutive inspections.
Kind and respectful staff
People received kind care, and staff protected their privacy and dignity. Staff understood people's individual needs and how to protect them from abuse.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Safe recruitment
The home completed pre-employment checks before staff started work.
“Recruitment processes were safe. Pre-employment checks were performed on staff to ensure they were suitable to work for the service.” from the report
Cultural food choices
People's cultural and religious food preferences were respected, including access to a halal diet.
“People were provided with food options in line with their cultural preferences and beliefs” from the report
Incomplete risk information
seriousSome care plans and risk assessments were missing or out of date. This included risks linked to medicines, sensory needs and the environment.
“Risk assessments and care plans relating to the health, safety and welfare of people were not always completed or reviewed regularly.” from the report
Medicines safety
seriousA staff member without medicines administration training was asked to give medicines. There were also no clear instructions for when required medicines.
“People were at risk of not receiving their medicines safely.” from the report
Consent and capacity reviews
seriousMental capacity assessments were sometimes not reviewed for several years. The home also did not ensure an Independent Mental Capacity Advocate was available in relevant cases.
“Some of them were not reviewed for several years and had not considered that people's capacity could fluctuate or change.” from the report
Weak management checks
seriousThe provider's audits and monitoring did not identify all the shortfalls found by inspectors. There was no action plan to drive improvement.
“The provider's internal governance, systems and processes had not fully identified the shortfalls we found.” from the report
Limited activities and independence
needs fixingPeople had limited opportunities for meaningful activities based on their interests. Access to the kitchen was restricted by a padlock, which did not promote independence.
“there were limited opportunities to engage in meaningful activities based on people's interest and hobbies.” from the report
Hygiene problem
needs fixingInspectors found that one bedroom had a strong urine odour, and the measures taken had not removed the concern.
“one person's bedroom had a very strong odour of urine.” from the report
- 01How have you updated each person's care plan and risk assessment, and how often will these now be reviewed?
- 02What checks ensure only trained staff administer medicines, and where are the instructions for each person's when required medicine?
- 03How are mental capacity assessments and best-interest decisions reviewed when someone's capacity may change?
- 04What activities and skills teaching are now available to support each person's interests, independence and future goals?
- 05What action has been taken to improve quality audits, incident reporting and the hygiene concerns identified by inspectors?
This was a focused inspection of Safe, Effective and Well-led, following specific concerns; Caring and Responsive were not inspected or rated in this report. This explanation was written from the published report of 11 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2022
Lime Lodge was inspected but not rated; inspectors found good PPE use but gaps in infection-control policies, cleanliness, training and vaccination checks.
This was an unannounced, targeted inspection on 23 February 2022. It focused on infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19.
The home had enough personal protective equipment, and staff were seen using it correctly. Cleaning schedules were in place, weekly infection-control audits were completed, and people were supported to access the community safely.
However, the infection-control and visiting policies were out of date. Some bedrooms were not hygienic and had a strong unpleasant smell. Some staff had not completed infection-control training, and vaccination checks for visiting professionals were not effective.
The home was inspected but not rated. This means the inspection did not give a quality rating for the service, and it only reported on the areas checked.
Correct use of PPE
There were ample supplies of PPE, and staff were observed wearing it correctly.
“There were ample supplies of personal protective equipment (PPE) available and the staff were observed to wear them correctly.” from the report
Community access
People were supported to go into the community in a way intended to reduce infection risks.
“People were supported to access community in a way that mitigated the risk of catching and spreading infection.” from the report
Testing and social distancing
Inspectors were assured that the home was accessing testing and meeting shielding and social-distancing rules.
“We were assured that the provider was accessing testing for people using the service and staff.” from the report
Cleaning arrangements
Cleaning schedules and weekly infection-control audits were in place, although some bedrooms still needed more thorough cleaning.
“Cleaning schedules were in place and regular cleaning took place. Infection prevention control (IPC) audit was completed weekly.” from the report
Out-of-date policies
needs fixingThe infection-control policy was not up to date. The visiting policy was also not aligned with government guidance.
“We were not assured that the provider's infection prevention and control policy was up to date.” from the report
Bedroom cleanliness
needs fixingSome bedrooms were not hygienic and had a strong unpleasant smell. Inspectors asked the provider to clean those areas more thoroughly.
“some of the people's bedrooms were not hygienic and there was a strong, unpleasant odour.” from the report
Incomplete staff training
needs fixingSome staff had not completed infection-prevention and control training. The provider was asked to ensure all staff completed it immediately.
“Some staff did not complete the IPC training. We asked the provider to ensure that all staff complete the IPC training immediately.” from the report
- 01Have all affected bedrooms been thoroughly cleaned, and how do you now check for unpleasant smells or hygiene problems?
- 02Are the infection-control and visiting policies now up to date and aligned with current guidance?
- 03Have all staff completed infection-prevention and control training?
- 04How do you check COVID-19 vaccination or exemption status for staff and visiting professionals?
- 05What evidence can you show that the actions requested after the inspection were completed?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 30 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lime Lodge
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- July 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- May 2012
Registered with the Care Quality Commission on 22 May 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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