Archived: The Lime Trees

The Lime Trees is a care home that provides accommodation and care to a maximum of 20 older people who may also be living with dementia. There were also a number of younger people staying at the home, on a respite basis, who were recovering from strokes or a similar health crisis. On the day of the inspection there were 11 people residing at the home.

There was a registered manager in post but they were not available during our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe at the home. They told us that staff were kind and respectful and they were satisfied with the numbers of staff on duty at the home.

The management and staff at the home had identified and highlighted potential risks to people’s safety and recorded how these risks should be reduced.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) and told us they would presume a person could make their own decisions about their care and treatment in the first instance. Staff told us it was not right to make choices for people when they could make choices for themselves.

The service had followed the appropriate procedures if someone needed to be deprived of their liberty for their own safety. However, the relevant and required notifications regarding Deprivation of Liberty Safeguards (DoLS) were not to being sent to the Care Quality Commission (CQC).

People had access to healthcare professionals such as doctors, dentists, chiropodists and opticians and any changes to people’s needs were responded to appropriately and promptly.

People told us staff listened to them and respected their choices and decisions.

People using the service and their relatives were positive about the management of the home. They confirmed that they were asked about the quality of the service and had made comments about this. However, action was not always being taken to address these comments to ensure high quality care was delivered.

Although the service had a number of quality and safety audits these were not always effective in maintaining a safe environment.

Below is a summary of what we found. This summary discusses what people using the service, and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

One person's said, "they are good to me here." We looked at five care plans, and generally these contained relevant information regarding the needs of people. However, we found that a number of areas of risk had not been addressed in three people's care plans and risk assessments. Care plans and risk assessments did not provide guidance for staff on how to prevent the risk of the person becoming dehydrated.

Staff we spoke with were aware of safeguarding and who to contact if they were concerned that a person who uses the service was being abused. However, they told us that they had worked at the service for two years and had not received any training on safeguarding vulnerable adults. There was not clear procedure to tell staff how they should respond if they had a safeguarding concern.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We spoke with the provider and deputy manager they were unaware of how the MCA or DoLS applied to the service. The keypad lock was in use on the front door which prevented people who use the service from leaving if they wished to. We looked at five people's care records and there were no capacity assessments relating to this restriction. One person, who had a diagnosis of dementia, had bed rails fitted to prevent them from falling out of bed. However, there was no assessment to show that this was an appropriate restriction on the person's liberty.

Is the service effective?

People said that the service made sure they had access to a range of medical professionals to meet their care and treatment needs. One person told us that, "I see my doctor, I just ask staff and they arranged it." Records showed that people were accompanied by a member of staff to hospital appointments. However, people's needs were not always addressed as guidance on how to handle the risks resulting from providing care to people who used the service was not available.

People who use the service told us that staff understood how to meet their needs. One person said, "the staff are good." We looked at areas of mandatory training and found that some staff had not received regular training updates. We looked at the supervision records for four staff and found supervision was not taking place regularly.

Is the service caring?

We spoke to the five people who currently used the service. They said that they felt their needs were being meet. However, we found there were gaps in care records that meant that people's need were not fully identified and meet. Staff were not provided with guidance about how they should meet people's needs.

Is the service responsive?

Where people's needs had changed they had been assessed and referred to the appropriate professional promptly. For example, people who used the service had been referred to a dietician if they need support to meet their nutritional needs. People's care records Showed that they had access to a range of health services and social care support.

Is the service well-led?

We looked at this supervision records for four staff and found supervision was not taking place regularly. While all four supervision records showed that staff had received supervision in April 2014 they had not had any supervision for a year prior to this. Staff told us that their experience of supervision had been mostly informal discussions with the manager. Staff told us that they had not received an appraisal in the last year. Staff had not received appropriate professional development. The provider was not able to show us that a survey of people's views had been carried out, and was unable to give us any other examples of how they would do this. People who use the service and their representatives were not asked for their views about their care and treatment.

People's care records showed that they were at risk of falls and three of the five people who use the service had recently had a fall on more than one occasion. The provider did not have a system in place to monitor the number of falls people were having and to identify the possible reasons why the falls had occurred. We looked at the "monthly care reviews and audit records" for all people using the service. These had not been completed for a year, the deputy manager had only recently (in April 2014) began to review and audit care records. Care records had not been reviewed and audited monthly as was the provider's policy.

The provider explained that they had introduced a system to carry out regular audits of care records to make sure that people received the care and treatment they needed. The provider showed us three recent audits of care records. These were used to make sure that changes to people's needs had been addressed. Two audits of medication had been carried out and these identified any issues that needed to be addressed. The deputy manager explained that these issues were addressed with staff to make sure that medication records were accurate and people got their medication. Systems were in place to make sure that care and treatment was safe and met people's needs.

People's personal records including their care plans were accurate, and updated at regular intervals. Records were kept securely and could be located promptly when needed. The deputy manager explained that when the office was not in use the filing cabinet and office door were kept locked.

The provider had told us they would ensure that sufficient staff were always available to meet people needs. People told us that sufficient staff were available to meet their needs. One person's comments were typical when they said that staff were available if "you needed them.' The provider explained that the usual staffing level currently was four staff on duty throughout the day. The rota showed that this level of staffing was being maintained consistently. The provider had carried out needs assessments of people to make sure that sufficient staff were available to meet their needs.

On our inspection of 28 February 2013 we found that the care plans had not been checked so that people were protected against the risks of inappropriate and unsafe care. The provider did not have systems in place to identify, assess and manage risks to the health, safety and welfare of people as regular audits of the quality of care were not being carried out.

We found that six of the seven care plans and risk assessments we reviewed did not contain accurate information about people's needs. Six of the care plans had incomplete or contradictory information regarding people's needs. Records relating to people were not accurately maintained and important information about their needs had not been recorded. People were at risk of receiving unsafe care and treatment as accurate records were not being maintained. The warning notices served on 12 December 2012 had not been complied with.

Staffing levels did not always meet people's needs. People gave examples of having to wait for staff when they needed support with their care. We observed that staff were not available at lunch time to meet people's need as there were insufficient staff available.

There were no quality assurance systems in place to make sure that people received safe and appropriate care. The six care plans and risk assessments we looked at did not show that they had been audited and reviewed to protect against the risks of inappropriate care and treatment.

Care records were not accurate or available to ensure that people received safe and appropriate care. Five of the care plans we looked at contained contradictory information regarding people's needs.