Archived: Lyme Regis Care Home with Nursing

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service under a new legal entity. This key question has been rated requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 50 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Assessments of people’s needs were not always comprehensive, and people’s care plans had not always considered the full range of their diverse needs, including psychological and emotional well-being. Different parts of people’s care and treatment were not efficiently coordinated to ensure consistently positive outcomes for them. People did not always have complete and accurate risk assessments in place for each person. Staff worked with insufficient guidance and had not been supported to mitigate risks to people leaving them at risk of harm from aspects of their care needs. For example, we reviewed 1 person’s care plan which stated, “I like to have coffee and a cigarette to start my day.” The person’s smoking habit had not been comprehensively assessed or planned with the person or their representative, and associated risks were not identified or effectively mitigated. There was no risk assessment in place to provide detailed guidance for staff on how to support them to smoke ensuring the person and other people living at the home were safe.

People and their representatives were not always involved as fully as possible in their needs assessment to ensure all needs were captured and understood. A relative told us, “Some people cannot judge when they are at risk. Regular consultation is needed with their relatives.

Miscommunication has been a problem leading to avoidable mistakes. It would be helpful to use other methods of communicating both with residents and relatives.”

Staff did not always keep clear, comprehensive care records to support reviews and evidence of appropriate action was taken in response to changes in people’s needs noted. For example, the daily recording of personal care provided to people, including oral care, was inconsistent across all personal care tasks undertaken throughout the day.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Care and support were not always planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and best use of technology. Care and support were regularly reviewed and updated, and appropriate referrals to external services such as dietitian or speech and language therapy team were made to make sure that all people’s needs were met. However, this was now always effectively monitored to ensure consistency of practice was fully embedded in the service.

Systems were in place to monitor people's nutritional intake and weights, and risk associated with dehydration and malnutrition. Care plans identified the level of support people needed from staff to prevent malnutrition and dehydration. This information was available to staff working in the kitchen. There was guidance in place to support people to eat safely when they were at risk of choking or needed their food to be a certain consistency. However, not all people's care plans outlined their food and drink preferences. This meant people were at risk of not having their nutrition and hydration needs met in line with their wishes.

We received mixed feedback from people and their relatives regarding meeting people’s nutrition and hydration needs. People and their relatives commented on poor variety of vegetarian options on the menu and lack of understanding of dietary impact on people’s complex healthcare conditions such as skin problems. Other relatives told us they noticed recent improvements and staff support people to maintain hydration.

Staff did not always feel they had enough time to support people with mealtimes and expressed concerns about quality of food. One member of staff told us, “The food is not what I would call quality food at all. Variety and quality are very poor. Ordering and supply of the food is terrible too as they often run out."

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Staff did not always work collaboratively across services to understand and meet people’s needs. Information was not always effectively shared between teams and services where they worked together to deliver a person’s care. Not all relevant staff were proactive in working with other services when multidisciplinary involvement was required, and any actions were not always followed up on as needed. This meant people’s care was not always effectively coordinated, to ensure they received support and treatment they needed timely and consistently.

We received mixed feedback from people and their relatives about the coordination of care and support at Lyme Regis Care Home with Nursing, and on how staff worked together with other health and social care professionals and with them to achieve their desired outcomes. Comments included, “They organised physiotherapist for [my loved one]. I had to ask him to get the doctor in. They don't keep you up to date, you have to ask” and “Sadly I do not yet feel confident to take a break for 2 weeks. This is because the presence of relatives encourages staff not to cut corners at the detriment of [my loved one].”

The provider had not taken full responsibility for ensuring that care and support was coordinated, leaving it to other agencies or relatives to manage. Care assessments did not always consider the full range of people’s diverse needs. We received mixed feedback from visiting health and care professionals about collaborative working. Comments included, “There are some concerns around organisational structure and staffing levels. The absence of a dedicated admin team puts additional pressure on nursing and management staff, who appear rushed and stretched. This leads to delayed email responses, and on occasion, the email inbox was full and messages bounced back.”

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

People’s day-to-day health and wellbeing needs were not always met, and people did not always experience positive outcomes related to these needs. When risks to people’s health and wellbeing were identified, the provider did not prioritise support to prevent deterioration as much as possible. For example, we found 1 person did not have a toothbrush in their bedroom. We reviewed their care plan which identified they were at risk of oral deterioration and required staff to prompt and encourage them to clean their teeth. We found no evidence to show that person received any support from staff with their oral health care since their admission 5 days before we inspected. We also found toothbrushes in bedrooms of 2 other people appeared dry and unused. The registered manager had identified that not all service users had toothbrushes in their rooms during ‘walk around’ conducted 7 weeks before we inspected. The provider did not follow best practice guidance on maintaining oral health for people in a care home. People should be supported with brushing their natural teeth at least twice a day with fluoride toothpaste. When reviewing daily care records, we found some people only had oral care support once a day. This meant people were not consistently supported to maintain they oral hygiene and were at risk of oral health deterioration.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Processes for monitoring the effectiveness of people’s care, treatment and support were not always effective in ensuring actions were always taken to continuously improve the service. The provider did not always understand what expectations and positive outcomes look like according to the legislation, national standards and evidence-based good practice guidance relevant to their service. Assessments of people’s needs were not always comprehensive and expected outcomes were not always identified. We found no evidence the provider actively sought feedback from health and social care professionals and stakeholders as appropriate when monitoring individual outcomes.

The provider sought feedback from people in residents’ surveys and regular residents’ meetings. However, those were not used to understand the expectations people had about the care they receive and what positive outcomes look like for them. Relatives told us they were not regularly approached by the provider requesting formal feedback about the service. Comments included, “Just the once my opinion has been asked about the service. I was indirectly invited to a residents meeting held by the manager, 8 months ago. There was no meaningful dialogue and no follow through with promises made to [my loved one] and other attendees.” Minutes from residents' meetings showed people were asked directly and individually for feedback about aspects of the service such as meals.

We reviewed the most recent residents’ survey from September 2024 which included an action plan to complete following feedback gathered. Completion timescales on the action plan were set mostly for the end of 2024. None of the actions on the action plan were marked as completed with most actions marked as ‘ongoing.’ For example, one of the actions identified was to increase numbers of stimulating and engaging activities for people and to allocate one to one time to individuals who spend long periods of time in their bedrooms.

We received mainly negative feedback from relatives about choice of activities at the service. Relatives expressed their concerns about lack of mental stimulation experienced by their loved ones. Comments included, “Staff don't have time to have a chat with [my loved one]. There's not enough for [them] to do.”

We reviewed minutes from residents’ meeting that took place in June 2025. One resident expressed their wish to go on “regular excursions out” and “was particularly keen to go out to buy some fish and chips.” Activities coordinators were asked to continue looking for transport and to take some people out on a regular basis.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff had received training in the Mental Capacity Act (MCA) but did not fully understand or always follow the principles of a best interest process in accordance with legal requirements, when a person lacked capacity to consent to the arrangements for their care and treatment. Consent to care and treatment and subsequent best interest’s decisions had not always been obtained in line with legislation and guidance. When people were assessed to lack mental capacity to make particular decisions for themselves, people’s family and friends were not always included or involved in making decisions in their best interest. That included their legal representatives, people holding power of attorney and lawfully acting on behalf of a person using the service, had not always been involved in all relevant decisions pertaining to their care.

Staff demonstrated some working knowledge of the relevant legislation but lacked guidance on how to put these into practice effectively to ensure that people’s human and legal rights wereconsistently upheld and respected. Evidence demonstrated staff were not always clear and did not follow national guidance in relation to consenting processes. For example, we reviewed MCA assessments and consents to care and treatment for 3 people. These assessments included acts intended to control or restrain in the form of bed rails on their bed. The assessments and subsequent best interest decisions had not been completed in line with the MCA. We found mental capacity checklist forms and subsequent best interest checklist forms used were incomplete and did not clearly record the individual’s involvement in actions undertaken on their behalf or in any decisions affecting them, consideration of the individual’s past and present wishes and preferences about the matter in question or who was involved in making best interest decisions for them. The use of less restrictive options was not considered or recorded in the best interest decision process. Where a person had restrictions in place such as a sensor mat which enabled staff to monitor the person's movements, there had been no assessment of their capacity to consent to these, and no decisions made in their best interest. This meant people had restrictions in place which may not have been in their best interest. All 3 people we reviewed, had a family member appointed as their legal representative holding power of attorney. There was no evidence of their involvement in the decision-making process for any of decisions assessed for 2 of them. Principles of MCA were not fully understood and followed in line with the MCA assessment process. This meant people’s human and legal rights were not always understood and respected.