The Limes

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The registered manager was open to us where gaps in their records and systems existed. There was a willingness to improve. The provider did welcome and support an open culture which was supported by staff feedback to us. Staff were confident to identify poor practice and told us concerns when raised would be acted on. People told us staff were kind and compassionate. Staff and management fed back passionately about the care being delivered to people and spoke fondly of the people they were supporting. Staff were able to share positive examples of where they had gone above their role to do things for people. This included supporting people to attend places of worship, cultural events and celebrating birthdays.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. There was a stable management and staff team. People, their families and staff knew who the management team were, and how to contact them. People and relatives told us the management team was caring and approachable. One person said, “Definitely recommend the home.” Staff knew their roles, responsibilities and how to support each other. They told us they felt valued by the management team.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident to report, whistle blow and raise concerns if needed. Staff were positive about the management who were open, listened and acted upon feedback. A staff member told us, their training included safeguarding and how to keep people and themselves safe. Another staff member told us about a safeguarding concern and how it was dealt with successfully. The provider had processes to inform staff how to whistle blow. Staff were able to raise concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. We saw managers had addressed concerns related to potential discrimination. For example, adjustments had been made to ensure all staff were valued, such as making reasonable adjustments to support staff so they could work safely. There were systems in place for matching staff to people, for example, if a person spoke a particular language or if a person wanted a male or female to support them. Staff received training relevant to their roles.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about known risk, performance and outcomes. Staff could access all required policies and procedures. Managers held regular meetings with staff, during which they discussed any concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Notifications were submitted to CQC as legally required. The provider had a system for monitoring incidents and learning from important events. People told us they were contacted to ask for feedback, and this was acted on. Unannounced spot checks took place on staff to check on the quality of care people received.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Refurbishment of the home was designed with people in mind. This included the addition of a café area that would be for people, families and local communities to meet up, enjoy and maintain important local connections. Staff told us local schools and colleges supported the home with staff placements. We were told this was a positive way to introduce potential new staff into care, whilst supporting people in the home to meet new people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The management team demonstrated they wanted to drive the improvements and told us they were committed to do this at The Limes and their other locations. Best practice and ideas were shared. One staff member told us they got together with other activities staff to learn new ideas and initiatives from other homes. Assistive technologies were balanced against people’s consent and safety to support positive outcomes.