CQC report explained · a residential care home
What the CQC found at Limefield Court Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection risks were being managed through testing, protective equipment, cleaning, social distancing and outbreak procedures. Agency staff were used when needed during COVID-19-related staffing pressures.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, January 2022
Inspected but not rated; inspectors found good infection control and visiting arrangements during the COVID-19 outbreak.
This was an announced, targeted inspection on 14 January 2022. Inspectors checked infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
Inspectors were assured that the home was using personal protective equipment safely, carrying out testing, managing outbreaks and admitting people safely. All staff had received COVID-19 vaccinations and took part in regular testing.
The home had a separate visiting room with its own outside entrance. Visits were booked, visitors completed a COVID-19 test and wore appropriate protective equipment. Relatives told inspectors that this system worked well.
The service was inspected but not rated. This means the visit did not give the home a Good, Requires improvement or Inadequate rating.
Infection control
Inspectors were assured that the home used protective equipment safely and had up-to-date infection control arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Testing and vaccination
Staff had received COVID-19 vaccinations and took part in regular testing.
“All staff had had their COVID-19 vaccinations and took part in the regular testing programme at the home.” from the report
Visiting arrangements
The separate visiting room had an outside entrance, bookings were used and the room was cleaned between visitors. Relatives said the system worked well.
“A separate visiting room had been built in the lounge, with an external entrance.” from the report
Managing infection risks
Inspectors were assured that the home could prevent and manage outbreaks and admit people safely.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
No nominated essential care giver
minorNo resident had a nominated essential care giver. Inspectors advised that this role could also provide emotional support, and signposted the provider to resources.
“The registered manager told us no one living at Limefield Court had a nominated essential care giver (ECG) as the staff provided all the care people needed.” from the report
- 01How are visits arranged now, and is the separate visiting room still available?
- 02What happens to care and staffing levels if staff are absent because of COVID-19 or another outbreak?
- 03How often are staff and residents tested when there is an infection risk?
- 04Can a relative be nominated as an essential care giver to provide emotional support?
- 05How do you check that staff are using protective equipment correctly?
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 25 January 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, October 2019
Limefield Court Retirement Home is rated Good overall; inspectors found safe, kind and responsive care, but management needs to show consistent improvement over time.
Inspectors visited on three dates. They spoke with people living at the home, relatives, staff and health professionals. They also checked care plans, medicines records, staff files, training, safety records and management checks.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found improvements in risk management, cleanliness, activities, dignity, medicines, staff training, meals and personalised care. They found no evidence that the concerns raised during the inspection had caused people harm.
Well-led was rated Requires Improvement. Management systems had improved and the home was no longer breaking regulations, but the service had previously been rated Requires Improvement three times in a row. Inspectors said the improvements needed to become established and consistent.
Kind and dignified care
People were treated respectfully and supported to maintain their independence. Inspectors saw people looking clean and well presented.
“People were nicely dressed and were seen to be supported in a dignified way.” from the report
Safer medicines
Medicines records were complete and staff had guidance for medicines given when needed. Checks were made on staff competence and storage temperatures.
“A review of records showed medication administration records (MARs) were completed in full” from the report
Improved cleanliness
The home had improved its hygiene standards, bought washable furniture, removed broken items and increased domestic staffing.
“During this inspection we found standards within the home had been improved.” from the report
Staff training
New staff completed an induction and staff received ongoing training in areas including dementia care, dignity, diabetes and end of life care.
“We found a comprehensive programme of training and support was in place to support and develop the team.” from the report
Personalised care
Care plans were reviewed and reflected people's changing needs, wishes and preferences. Staff were kept informed through handovers and updated care plans.
“Individual support plans were kept under review so that information reflected people's current and changing needs.” from the report
Improved meals
People reported that meals had improved, with a choice of options. The kitchen was found to be clean and organised, and dietary needs were understood.
“People we spoke with said there had been improvements in the meals provided.” from the report
Management consistency
needs fixingManagement systems had improved, but inspectors could not rate well-led as Good because the home needed to show consistent good practice over time.
“Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.” from the report
Improvements need embedding
needs fixingThe home had previously received Requires Improvement ratings three times in a row. Inspectors said the new systems needed to become established and demonstrate ongoing improvement.
“Therefore, to demonstrate effective management and consistent good practice over time these systems need embedding to demonstrate on-going improvements.” from the report
Staff working hours
needs fixingInspectors found that some staff worked excessive hours with few days off. The manager said this should improve when vacant care posts were filled.
“We did note that some staff worked excessive hours with few days off.” from the report
Activities still developing
minorActivities had improved, but inspectors said more work was needed. One person said staff did not always have time to provide activities.
“Whilst some improvements had been made these needed to be enhanced further.” from the report
- 01How are you making sure the improved management systems remain effective and consistent?
- 02How are you reducing excessive working hours and filling the care staff vacancies?
- 03What activities are available for people who need staff support, and how often do they take place?
- 04Have the fire risk assessment, legionella assessment and call bell servicing been updated or completed?
- 05What refurbishment work is still planned, and when will it be finished?
This was a follow-up inspection covering all five CQC questions; the overall rating and four question ratings improved to Good, while Well-led remained Requires Improvement because consistent improvement had not yet been demonstrated over time. This explanation was written from the published report of 17 October 2019 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 Limefield Court Retirement Home
5 rated inspections over 3 years: the service has held its Good rating throughout.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Limefield Court Retirement Home →
- October 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Limefield Court Retirement Home →
- February 2019Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 2011.
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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