Lime House

“This service is a residential care home providing support to older people. At the time of the inspection 26 people lived at the service.”

“ ”

“We carried out this comprehensive assessment in response to concerns about the quality and safety of care people received.”

“ ”

“The provider’s systems for investigating, reporting, and learning were not robust, and appropriate actions were not always taken in response. Various concerns around the safety of people’s care, including health and safety, infection prevention and control (IPC) and medicine concerns were found during the inspection.”

“ ”

“We were unable to determine if people had received appropriate care or not as the provider’s oversight and monitoring systems were not robust. During the inspection, we found concerns around whether people received appropriate care around their personal care, oral hygiene, repositioning needs and night checks.”

“ ”

“Quality and safety in the service had not been maintained, and oversight and monitoring systems related to risks were not robust. Moving and handling practices were unsafe.”

“ ”

“Systems to monitor staffing levels were not robust. The provider did not have systems in place or use a dependency tool to determine safe staffing levels at the service.”

“ ”

“The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. There was limited evidence that people were involved in their care planning and reviews.”

“ ”

“Staff were kind, respectful and caring.We observed staff engage with people in a friendly and caring manner and their conversations with people were good natured. People’s privacy and dignity were respected.”

“ ”

“We were not assured person-centred care was always provided to people. Care plans lacked person-centred details and there were inconsistencies in care records. The service predominantly supported people living with a diagnosis of dementia and there was a lack of dementia support, dementia friendly signage and visuals in the service to meet people’s needs. Activities for people to engage within the service were limited.”

“ ”

“Governance systems were not robust. Some of the health and safety and IPC concerns were found via the provider’s auditing systems in August 2025 and September 2025, however, timely action had not been taken to address the concerns and issues remained during our inspection.”

“ ”

“The service was in breach of legal regulations in relation to person-centred care, good governance and staffing.”