What the CQC found at The Limes

Staff said they felt listened to, involved and valued. They described the management team as supportive.

“Staff told us the culture was open and supportive, and that they felt valued and informed.” from the report

Medicines were stored securely and at appropriate temperatures. Staff giving medicines had received training and competency checks.

“Members of staff handling and administering people's medicines had received training and had their competency to handle and give people their medicines safely assessed.” from the report

The home was on one level, which supported movement for people living with dementia. Rooms were personalised and people had communal and private areas.

“The environment met people's needs, most of whom were living with dementia.” from the report

Relatives said they were kept up to date about their family member's care, although some had not recently been involved in care plan discussions.

“Relatives told us they were kept up to date with their family member's care” from the report

Risk assessments and safety plans were not reliable. Concerns included falls, pressure areas, seizures, diabetes, continence and unsafe areas or items.

“People had been placed at risk of avoidable harm due to poor risk assessing and management.” from the report

Two safeguarding incidents were not reported to the local authority. One person was deprived of their liberty without lawful authority in place.

“We identified two safeguarding incidents that the provider had failed to report to the local authority as required.” from the report

The home could not show that people received enough to drink or that individual nutritional needs were met. This included concerns about people living with diabetes.

“The service could not demonstrate that people received enough to drink to sustain good health or that individual nutritional requirements had been met.” from the report

Capacity assessments and consent to care were not consistent. The home could not show that all conditions attached to one liberty protection authorisation had been met.

“Consent to care was not consistently in place and where it was, it was not always from the people who had legal authority to make such decisions.” from the report

Audits were missed or did not identify problems. Records were incomplete and the provider had no effective improvement plan or sufficient oversight.

“The provider's quality assurance systems had failed to ensure people received consistently safe and effective care.” from the report

COVID-19 policies were out of date and some infection control procedures were not followed. Inspectors also found a stained carpet and a poorly maintained pressure cushion.

“The provider's COVID-19 policy had not been updated since October 2020 and contained information which was not in line with current government guidance.” from the report