CQC report explained · a residential care home
What the CQC found at The Limes Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
The Limes Care Home is rated Requires Improvement; inspectors found kind, responsive care but important weaknesses in recruitment, records, consent and management checks.
The inspection was unannounced and took place on 20 September, 27 September and 10 October 2023. One inspector spoke with people, relatives and staff, and reviewed care records, medicine records, staff files and management records.
People generally felt safe and said staff were kind, attentive and responsive. Medicines were administered safely, there were enough staff, the home was clean, food met people's needs and people were supported to access healthcare, activities and the community.
However, staff recruitment checks were not reliable. Some safeguarding incidents were not reported to the right authorities. Some risk assessments and care plans lacked enough detail, CCTV consent had not been obtained promptly, and staff training and supervision checks were not effective.
The overall rating is Requires Improvement. Caring and Responsive were rated Good. Safe, Effective and Well-led were rated Requires Improvement. The home remains rated Requires Improvement after the previous inspection, and breaches were found in staff recruitment and good governance.
Kind and respectful staff
People and relatives were positive about the staff. Inspectors saw staff speaking kindly, spending time with people and supporting their dignity and independence.
“People and relatives were happy being supported by staff at the service.” from the report
Safe medicines
Staff were trained to give medicines safely. Their competence was checked regularly, and medicine checks and audits were completed.
“People were supported safely with their medicines. Staff were trained to administer medicines safely and had their competency to do this checked regularly.” from the report
Enough staff
People, relatives and staff said there were enough staff to provide timely support. Inspectors observed staff responding attentively to people's needs.
“People, relatives, and staff confirmed there were enough staff to support people safely.” from the report
Activities and community access
People were supported to go out regularly and to take part in activities suited to their interests, including artwork, games and cooking.
“People were regularly supported to go to places interesting to them, such as cafes, airfields, and local parks or to go out of the service to access local amenities.” from the report
Recruitment checks
seriousStaff files contained missing employment histories and incorrect or incomplete documents. The provider could not assure inspectors that suitable checks had been completed before staff were employed.
“The provider did not have safe and effective systems in place to make sure staff were recruited safely.” from the report
Care records and risk guidance
needs fixingSome risk assessments and care plans did not contain enough detail or had conflicting information. This could leave staff without clear instructions when people's needs changed.
“Some risk assessments and care plans were not detailed enough to guide staff how to support people safely.” from the report
Safeguarding reporting
seriousSome incidents that should have been reported to the safeguarding team and CQC were not reported at the time. The manager later reported historic events after inspectors raised the issue.
“The manager did not always have effective systems in place to make sure incidents where people were at risk of abuse were reported to the right authorities.” from the report
Consent for CCTV
needs fixingCCTV had been installed for more than a month without written consent from people or their representatives. The manager began obtaining consent during the inspection.
“However, they had not gained written consent from people or their representatives to have this installed.” from the report
- 01What checks have now been completed for every staff member's employment history and DBS documentation?
- 02How are you checking that safeguarding incidents and possible injuries are reported to CQC and the safeguarding team on time?
- 03How have you updated care plans and risk assessments where people's needs or equipment use have changed?
- 04What is the current process for obtaining and recording consent for CCTV?
- 05How often are audits, staff competency checks and supervisions now completed, and how will you show that actions are sustained?
This was an unannounced inspection covering all five key questions, including infection prevention and control under Safe; no registered manager was in post at the time. This explanation was written from the published report of 2 November 2023 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 The Limes Care Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2023
Registered with the Care Quality Commission on 17 March 2023.
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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At least 100 live-in carers within about an hour of Central Bedfordshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 83 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.