Archived: Lyme Regis Care Home with Nursing

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

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

This meant people’s needs were not always met.

This service scored 61 (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 were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People’s care plans were focused on their medical needs and lacked person centred details. We found very little information about people’s personal life history, wishes and preferences, passions and hobbies, cultural background and spiritual beliefs. Care plans didn’t include people’s goals or desired outcome. Care plans were not always developed in close collaboration with people and others important to them. Care planning was focused on people’s current healthcare needs rather than each person’s whole life, including their goals, skills, abilities and how they prefer to manage their health.

People had opportunities to discuss their interests and hobbies at residents’ meetings. This information was used to help plan social events and activities. However, information about people’s hobbies or interests were not always included in their care plans. We found no evidence staff took account of people’s backgrounds to identify activities and interests for those who chose not to participate in resident’s meetings. Staff did not always know about people’s personal histories and preferences and were not aware of individual goals they wished to be working towards and how best to support them to achieve their goals. This meant people were not always supported in expressing themselves in a way which reflected their personal histories and cultural backgrounds. Relatives confirmed that. Comments included, “There's nothing to stimulate [my loved one] at all there. [They] just stare at the walls all day. There's no newspaper. I bring the crosswords; I bring the book. There's no religious input at all. [They] used to be a priest. [They] have a very dull existence.”

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Processes were in place to involve the multi-disciplinary team when required to meet people’s needs. However, they were not always effective and consistently followed by staff. We reviewed records of people having regular input from other services; for example, speech and language therapy records were present and clear, there was input from the community mental health team, local GP surgery and frailty team. Staff co-ordinated people’s appointments, making sure other professionals were aware of the person’s treatment and ongoing needs. However, staff did not always follow guidance requested and provided information and feedback to professionals when needed. One healthcare professional told us, “At times, important clinical tasks such as taking bloods, monitoring residents, or amending / stopping medications can be delayed or missed. Communication can be inconsistent. Requests or instructions may not always be followed through, and there is often a lack of follow-up.”

Some staff expressed their concern at a lack of community engagement from the service. People were not routinely supported to access the community as part of the activities programme either in groups or as individuals and the community was not often invited into the service. A staff member told us, “We desperately need transport to take residents out. It is very difficult. We cannot go for walks because of the location; the traffic is too dangerous. One or two residents have asked about going shopping, but it never seems to happen.”

Relatives commented, “There could be more social engagement and activities. There is not transport at the service for activities and appointments.”

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People were supported to communicate effectively. The provider ensured people’s care plans and records captured ways that met their needs for meaningful communication and decision-making. People’s communication needs were assessed on admission and planned for. These plans were reviewed to ensure changing communication needs were met. Care plans detailed people’s individual communication needs, such as language and sensory aids such as glasses or hearing aids and any additional resources that staff might use to help with communication, for example pictures or technology. We reviewed a care plan for a person who had difficulties expressing their needs verbally at times due to their complex health condition. They had a voice enhancing gadget supplied by the NHS, which helped them to improve their voice output to make it more audible. Staff encouraged them to use at times when they were unable to audibly articulate their needs.

Within the service there were notice boards and staff spoke to people about events of the day and meal choices. However, some relatives told us there was a need for improvement in facilitating communication and providing accessible information to people and their representatives. A relative told us they cannot phone their loved one directly as staff don’t support them to ensure their personal mobile phone had been charged. Others felt provider’s policies, guidelines and contracts lacked transparency and visibility.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The provider had a policy and procedure in place that set out the steps someone would need to take if they had a complaint, and information on how to complain was accessible to people and their relatives. However, arrangements were not always effective and fully embedded in the service. One person told us that despite them raising complaints about their clothing, nothing was done about it. They showed us 3 mismatched pairs of socks they had.

We reviewed the complaints audit completed by the registered manager in January, March and April 2025. The complaint from this person about their clothing and socks were logged but not successfully resolved as the issue was still ongoing in July 2025. Following their complaint in April, the registered manager concluded, “the person appears to be forgetting they got their clothing items from the laundry.” The provider did not always take appropriate actions in response to a complaint. People were not always supported to escalate their concerns further when they did not see real change because of a complaint they’d made or when they were not satisfied with the outcome.

Relatives we received feedback from told us they haven’t needed to complain. All told us they would be confident to raise any concerns they had about Lyme Regis Care Home with staff or the management team and believed these would be dealt with. Comments included, "I've not had to complain, but any minor issues I brought up they've done their best to resolve. To put things in place for [my loved one]” and “I haven't needed to make a complaint.”
 

A survey had been issued to people in September 2024 and 24 people provided responses. All feedback received or concerns raised were used as opportunity to improve the service and the quality of care people received. However, all 13 relatives we received feedback from told us they were never approached by the provider to take part in any satisfaction survey.

Residents’ meetings were held regularly to support people to be actively involved in shaping the service. However, there was a lack of involvement with people and relatives when compiling care plans, none of the feedback we received suggested any significant involvement of people or relatives.

The provider made sure that people could access the care, support and treatment they needed when they needed it.

The registered manager told us they established a positive working relationship with the local doctor’s surgery. GP visits were requested for all newly admitted residents. The frailty team visited the home weekly to review any concerns escalated by staff and the team’s pharmacist provided support with regular medication reviews.

Staff escalated health or wellbeing matters and sought advice as needed. Referrals to external health professionals were made in a timely manner for further assessment. People received additional health support from a range of external clinicians such as speech and language therapists, dieticians, tissue viability nurses, community mental health team or occupational therapists.

We received mostly positive feedback from people and their relatives about access to health professionals when needed.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The provider complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes. For example, people with health-related mobility issues were provided with appropriate mobility aids to improve their experience and support independence.

All staff received training to help them understand equality and diversity and to identify and address discrimination.

Relatives told us their loved ones had access to health care when needed and did not report they experienced any inequalities.

The home maintained paper based multi-disciplinary records for recording health professional input and medical advice for each person. There were regular reviews of people’s care plans and risk assessments to ensure they were a true reflection of people’s current and changing needs.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People’s care plans in ‘Death and Dying’ section contained information about people’s wishes regarding end of life care. They included information about a Treatment Escalation Plan (TEP) and a Do Not Attempt Resuscitation (DNACPR) when the wish had been expressed by people. The registered manager told us, “For additional support, we register residents on palliative, end-of-life care pathways and with cancer diagnoses with [local] hospice, to help us manage end-of-life symptoms effectively, if needed.”

However, there was no evidence of recorded discussions with people or their relatives regarding end of life wishes and preferences and their end of life care plans lacked person-centred details. The provider did not always recognise people’s individual religious, social and cultural diversity or values and beliefs, and how these may influence wishes and decisions about their end of life care. These were not recorded in people’s care plans. However, people, and their representatives were involved in regular reviews and re-assessments of their end of life needs.

Details of advanced wishes or DNACPR did not always evidence people’s involvement in the original decision and any reviews in case they changed their mind in order to capture details whilst people still had the capacity to make decisions.

We reviewed care plans for 3 people who did not have ‘Death and Dying’ section of their care plan completed at all. One person did not have any information recorded to inform if they had DNACPR in place or not. This meant staff were not clear what were person’s wishes about attempting cardiopulmonary resuscitation. People were at risk of not having their end of life wishes and preferences met.