Limetrees

The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury.This incident is subject to further investigation by CQC as to whether any regulatory action should be taken.As a result,this inspection did not examine the circumstances of the incident.The service has also not been rated after registering in 2023.

We found inconsistent risk management practices across the service. Environmental risks were not always effectively controlled, including fire doors being obstructed or not functioning correctly and hazardous items such as razors and creams being left accessible. Fire safety arrangements were not robust; actions from the Fire Risk Assessment had not been completed in a timely manner.

Medicines management required improvement. We identified gaps in medication administration records (MAR) and controlled drugs records, including missing signatures, lack of second checks, and inconsistent audit processes. Medication audits were not completed at the required frequency, which reduced oversight and increased risk.

Care plans were often incomplete, inconsistent, or not up to date, particularly in relation to clinical needs, capacity assessments, and dietary requirements. We found conflicting information regarding people’s mental capacity and inappropriate or unclear use of Deprivation of Liberty Safeguards (DoLS) applications and authorisations. Staff lacked a full understanding of what mental capacity was and how this was applied to people’s care.

During the assessment, staff demonstrated positive, friendly, and respectful interactions with residents. People appeared comfortable in staff presence, and feedback from residents and relatives was generally positive about the caring nature of staff.

While there were examples of good engagement and activities, these were not consistently tailored or meaningful for all residents. Some people experienced limited stimulation, and opportunities to personalise care and routines were not always taken. At times we saw a task-based approach to care provided, rather than a person-centred approach.