CQC report explained · a residential care home
What the CQC found at The Limes Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2022
The Limes Retirement Home was rated Good; inspectors found safer systems and kind, responsive care, with some improvements still underway.
This was an unannounced, focused inspection. Inspectors looked at Safe, Responsive and Well-led. They visited the home, spoke with people, relatives, staff and the manager, observed care and medicines, and checked care plans, risk assessments, recruitment and other records.
Inspectors found that risks were assessed more clearly, medicines were managed safely, staffing was reviewed, and infection control measures were in place. People were supported to see visitors, take part in activities and make choices about their daily lives. Care plans had improved, although work on them was continuing.
The overall rating was Good. This was an improvement from Requires Improvement at the previous inspection, published in May 2021. The previous breach of Regulation 17 had been addressed, so the home was no longer in breach. The circumstances of a death that prompted part of this inspection were not examined.
Improved risk management
Risk assessments gave staff clearer guidance. Management meetings were used to discuss new risks and agree actions.
“Risk assessments provided guidance for staff in how to reduce the assessed risks to people.” from the report
Safe medicines and recruitment
Inspectors observed medicines being given safely. Records showed people received medicines as prescribed, and recruitment checks included references and DBS checks.
“Records showed people received their medicines as prescribed.” from the report
Choice and relationships
People were supported to make everyday choices, maintain relationships and receive visitors. They also had access to activities and the secured garden.
“People were supported to have visitors and maintain relationships with those important to them to reduce the risks of isolation.” from the report
Management improvements
The home had introduced electronic care planning and other quality checks. It also accepted local authority support and provided additional staff duties focused on improving systems and training.
“Since our last inspection, there had been several improvements made in the service and further improvements planned.” from the report
Care planning still developing
minorCare plans had improved, but the electronic care planning system was not yet fully developed. Further improvement was planned.
“The development of the new electronic care planning system was ongoing and further improvement was planned.” from the report
Staffing calculation still being developed
minorNight staffing had been reviewed and duties had changed, but a new system for calculating staffing numbers was still being developed.
“The registered manager told us a new system to calculate the numbers of staff to meet people's needs was being developed.” from the report
- 01What progress has been made with the electronic care planning system, and how do you check that records reflect each person's current needs?
- 02Has the new call bell system been fully installed, and what are the current response times?
- 03How are night staffing levels checked against people's changing dependency needs?
- 04How would you respond if a person's mobility, health or communication needs changed?
- 05What were the previous ratings for Effective and Caring, and when will these areas next be reviewed?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 7 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, May 2021
Rated Requires Improvement; inspectors found caring staff and safe medicines systems, but care records and night staffing needed improvement.
This was an unannounced focused inspection on 8 April and 20 April 2021. The inspectors looked only at Safe and Well-led because concerns had been raised about safety, pressure ulcers and care records.
The main problem was that care records did not always reflect people's current needs, preferences or risks. Some records were inconsistent, including information about dietary needs, oral care and repositioning. This was a breach of Regulation 17 on good governance.
Inspectors also had concerns about whether two night staff could always meet people's needs promptly. Medicines systems, infection control and cleanliness were found to be satisfactory. Relatives and professionals gave positive feedback about the caring approach.
The overall rating changed from Good to Requires Improvement. The provider was asked for an action plan, and the CQC said it would monitor progress and return for another inspection.
Kind relationships
Feedback about the staff and management was consistently positive. Inspectors also saw caring interactions between staff and residents.
“Without exception, we received positive feedback about the caring nature of the staff and management team.” from the report
Medicines
The home had systems for ordering, storing, administering and disposing of medicines. Staff training, competency checks and audits were in place.
“There were systems in place to reduce the risks to people using the service relating to the management of medicines.” from the report
Infection control
Inspectors were assured that the home used suitable infection prevention measures, including PPE, testing, hygiene and social distancing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Listening to families
The home collected feedback from residents and relatives and used it to make changes, including arrangements for private visits.
“This demonstrated their views were valued and acted upon, for example, advising on the arrangements for private visits.” from the report
Incomplete care records
seriousCare records did not always describe people's current needs, preferences or risk controls. Contradictions and omissions could lead to unsafe or unsuitable care, and this was a regulatory breach.
“Systems were either not in place or robust enough to demonstrate people's current care needs and preferences were accurately recorded.” from the report
Night staffing
needs fixingInspectors were concerned that two staff at night might not always meet the needs of residents who required two-person support, while also completing checks and domestic duties.
“We recommend the provider assesses the staffing levels at night in line with people's dependency needs to ensure they are receiving the care they need in a timely way.” from the report
- 01How have you updated care records so they reflect each resident's current needs, preferences and professional advice?
- 02How do you check that staff follow the care plans, especially for dietary needs, oral care and repositioning?
- 03How many staff work at night now, and how is this number matched to residents' dependency needs?
- 04Has the new call bell system been installed, and how do you monitor response times?
- 05What action plan did you send to the CQC, and which improvements have been completed since this inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 15 May 2021 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 Retirement Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodResponsive: Requires improvementWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 1 November 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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23 live-in carers within about an hour of Suffolk
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 £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
“Not only was she professional, polite and efficient but she bought a lovely smile and laughter to my parents home.”
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.