Archived: Lyme Regis Care Home with Nursing

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service under a new legal entity. This key question has been rated requires improvement.This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, safe and effective staffing, safe environments and the ways people’s medicines were managed.

This service scored 44 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had established a process of learning from events that had either put people and staff at risk of harm or had caused them harm, to improve the service. However, it was inconsistent and not always effective. The provider could not assure themselves all safety incidents were appropriately reported, escalated and investigated, and culture of learning was fully embedded in the service.

When incidents and accidents records were completed, reviewed and scrutinised by the registered manager, potential themes and trends were not always analysed or identified. The registered manager told us since October 2024 when the electronic recording systems were introduced at the service, they were only able to review each accident and incident form separately and were unable to audit them to analyse trends and themes, as they were not able to use the system to generate the report. That meant opportunities to identify where patterns of incidents may have been related to environmental or staffing factors were missed.

De-briefing took place and staff felt encouraged and confident to raise concerns and report incidents and near misses and felt supported by the management when they did so. A member of staff told us incidents were discussed at the meetings, staff were given opportunity to express their concerns, share knowledge and were offered support when needed. Daily flash meetings were held to communicate any updates and provided opportunity for staff to highlight any areas of concern. However, reporting of the incidents was inconsistent which meant de-briefing and discussions not always took place for all incidents and near misses and was not effective to drive improvements and embed lessons learned.

When identified, lessons learned were discussed and communicated widely to support improvement during regular staff meetings. However, learning for the future about the cause of incidents and accidents was not always effective to prevent re-occurrence. For example, a significant incident had taken place due to the premises not being fully secure. When we inspected, we found the premises still not secured. This meant people were able to leave without staff noticing and premises were accessible to unauthorised entry by members of public.

We will address these concerns more fully in other sections of this report – safeguarding and safe environments.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems and processes to coordinate and maintain continuity of care and support were not applied consistently. Information sharing and communication with healthcare partners and people were not always effective.

Pre-assessment paperwork was completed involving people, relatives and partners prior to people moving into the service, and was shared with staff. The registered manager told us, pre admission assessments were completed and agreed with people or their representatives prior to admission, and full care plans were completed within the 72 hours since admission.
Assessments of needs were communicated with staff when people moved into the service or returned from a hospital stay via daily handovers and flash meetings. Systems were in place to ensure information was shared with healthcare partners, so people received the care and support they needed in line with their individual plans. For example, hospital passports if they were being admitted into hospital.

However, evidence showed processes of safety and continuity of care through a collaborative, joined-up approach to safety had not always been consistently applied by all staff, nor was fullyembedded in the service. Processes did not always involve people in their care along with staff and other partners.

We received mixed feedback from health and social care professionals. Comments included: “Communication can be inconsistent, requests or instructions may not always be followed through, and there is often a lack of follow-up. There have been some challenges with the timely collection of medications, and occasional delays in following through with shared care tasks. These issues seem largely tied to staffing shortages and time constraints.”

We received mixed feedback from people and their relatives about maintaining continuity of care and their involvement in creating and reviewing people’s care records. Most relatives told us they did not see their loved one’s care plans. Comments included, “Care plans are not shared with me.” Another relative told us they have been asked to sign their loved one’s care plan 6 months after their admission.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People and relatives felt the service provided by Lyme Regis Care Home with Nursing was not consistently safe. Comments included, “I’m not confident my loved one is always safe because of the lack of vigilance regarding health and safety, which is not understood by some staff” and “I think [my loved one] feels mostly safe. My [loved one] doesn't like their door shut which meant that others wander in. [My loved one] is bedbound and [they] don't ring the bell because staff don't come quickly.”

The provider had safeguarding policies and procedures in place, but they were not fully understood or consistently followed by staff. People were always protected from avoidable harm, neglect and abuse. The provider was not always fully engaged with local safeguarding systems and had not always made referrals to the local safeguarding team following incidents where people had been at risk of abuse. During the inspection, we reviewed an incident / accident record reporting a person had sustained self-inflicted bruising when supported by staff with personal care. This was not identified, followed up or raised with the local authority. The registered manager signed off this record, however had not shared concerns appropriately with local safeguarding systems. This meant external scrutiny was not always possible to ensure people were safeguarded from abuse.

Staff expressed they had awareness and understanding of abuse or neglect and knew what to do to make sure that people’s human rights are not breached or violated. However, we found staff including the manager had not always recognised when abuse or neglect may be occurring and had not always responded quickly enough to concerns.

Staff lacked understanding of safeguarding and how to take appropriate action. For example, the door leading to the property from the car park was left open and unattended during our site visit. In addition, window leading to the communal bathroom on the lower floor was left wide open which left the floor not secured to prevent unauthorised entry. People who had Deprivation of Liberty Safeguards (DoLS) order in place or applied for, were at risk leaving the building unaccompanied and without staff knowledge. This meant people were at risk of stranger danger and at risk of injury if they left the property.

During our visit we observed staff placed cantilever tables in front of people who were sitting in armchairs in the communal lounge, causing unnecessary restriction if they chose to mobilise independently. We observed several walking aids placed together on one side of the communal lounge which were not in people’s reach. This issue had been highlighted by the local authority during their monitoring visit conducted on 15 May 2025. We raised this with the registered manager who immediately addressed this with staff on duty. Staff confirmed they were aware this practice was inappropriate but could not explain why it had continued.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some risks to people’s health, safety and welfare were identified for example, risks associated with people’s mobility, swallowing difficulties and diabetes. However, not all risks relating to people were assessed and managed appropriately, with the involvement of people or their representatives, so they fully understood all decisions about their care and risk mitigation. For example, we reviewed the care plan of the person most recently admitted to the home, 4 days before we visited. Not all sections of their care plan were fully completed or included crucial information on how to keep them safe and meet all their needs. The person was a smoker, but there was no smoking risk assessment completed despite them having prescribed flammable cream. This meant people were at risk of harm and at risk of not having all their needs met.

People and relatives told us they were not always involved in care planning and managing risks and they were not always confident in the staff’s ability to keep them safe from risk of harm. Comments included, “I haven't seen [my loved one’s] care plan. Nursing care can be erratic and inconsistent when dealing with chronic conditions like diabetes. Diabetic medicines are not always given at the correct times” and “I don't think [my loved one] has a care plan.”

Staff told us they were given enough information about people’s risks and how to keep people safe when providing their care. Staff told us care plans were easily accessible via provider’s electronic recording systems and included information about people’s individual needs and risks.

However, staff needed additional support to assist them understand how to gather and analyse information to ensure they created robust risk assessments, particularly in relation to working with people who displayed distress reactions. Staff did not consistently support people when they communicated their emotions, needs or distress, in a positive way that protected their rights and dignity. For example, we observed 1 person who was bed bound in their bedroom repeatedly pressing a call bell and becoming increasingly distressed, tearful and anxious. Staff were not present on the floor and attended to call bells to switch them off without spending meaningful time or engaging in one-to one interaction to relieve their distress. We reviewed their care plan which instructed staff to take time to talk to this person, so they do not become isolated in their room. Staff were not following the care plan in place for the person exposing them to an increased risk of emotional distress and deterioration of wellbeing.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.
The provider’s approach to assessing and managing environmental risks was inconsistent. Arrangements were in place to monitor the safety and upkeep of the premises, bringing in professionally qualified people to complete the necessary environmental and equipment checks. However, those arrangements were not always robust and effective and did not identify shortfalls found at this inspection. The safety of the premises, communal and personal spaces(such as bedrooms), and the living environment were not always checked and managed to support people to stay safe. The premises were a blend of converted old cottage with purpose-built areas, both of which needed repairs. For example, we identified several pipes, possibly connected to the central heating, which posed a risk should anyone fall in their vicinity. Radiator covers were not always securely fixed to walls meaning those people who were ‘furniture walkers’ or anyone who stumbled and used the cabinets to steady themselves were at increased risk of falls and injury. Wooden door frames leading to patio areas from bedrooms on the lower floor were rotten; pieces of them had become detached and were leaning on the ground or against the base of the doors.

The premises were not fully secured to prevent unauthorised entry, or people who had authorised Deprivation of Liberty Safeguards (DoLS) from leaving the building unaccompanied and without staff knowledge. On arrival at the service, inspectors were able to access parts of the premises from the car park, and while they did not, they could have entered a communal bathroom and accommodation through eternal doors opened from people’s bedrooms. The patio doors from 3 bedrooms had slide bolts as their only security which, particularly as the rooms were being used for respite stays for people not well known to the service, may not provide sufficient security to reduce the risks of people leaving the service.

We also found the sluice room on the lower floor was left open and not locked as per providers policies and procedures. No staff were present on the floor and the sluice room was accessible to people living at Lyme Regis Care Home with Nursing. This meant people were at increased risk of avoidable harm. We raised this immediately with the manager and they took appropriate action to address this with the team.

Relatives expressed concerns about safety of the environment and poor maintenance of the premises. Comments Included, “The building is not fit for purpose though I can see superficial attempts have been made to accommodate it for the residents. For example, I stumbled many times on the uneven floor in the corridor leading to the living space and into the smaller staff office. There is insufficient space in the main living area for the numbers of residents and relatives, creating far too many trip hazards. This is unsafe and a serious accident waiting to happen. I tripped over the flex to an electric chair when trying to manoeuvre around other obstacles such as the numerous small tables, chairs where people are seated at the table and others seated in armchairs."

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider had arrangements in place to ensure there were always enough competent staff on duty to support people to stay safe. When required, agency staff were deployed to cover vacancies and absences. However, staff did not always have the right mix of skills to meet all people’s needs.

When we inspected Lyme Regis Care Home, night staffing consisted of 2 care assistants and 1 registered nurse to support 26 people. Some people needed 2 staff to support them with personal care or mobility meaning there may be times where there could be no staff available to assist should there be an emergency during a medication round for example. There was no staff member permanently present on the lower floor, where up to 9 people resided, some of them bedbound. This meant people were at risk of harm or at risk of not having their needs met if they required support and were not able to press a call bell or in the emergency.

Three staff would not be enough to maintain the safety of 26 people in an emergency situation. For example, fire evacuation plans were to move people from the lower to upper level of the service using sleds. It was not clear how this could be achieved. The provider supplied accommodation for some staff on site and told us the off-duty staff who lived in the accommodation nearby, would support any evacuation. We requested assurance this was a contracted agreement with each staff member as off duty staff would be under no obligation to always be in the staff accommodation when not on shift in the service. We did not receive evidence from the provider this was the case.

We received mostly negative feedback from relatives regarding staffing levels. Comments included, “There is never consistently enough staff on duty, especially over the weekend. The skill mix can be dire at times”, “Staff are very slow to respond. Sometimes [my loved one] has to wait 20 to 30 minutes before someone comes.”

Staff recruitment was based on filling vacancies rather than on the skills and values of applicants. Checks were minimal, and signs of unsuitability were not always given due attention.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

During our SOFI, we observed people appeared relaxed and at ease when supported by staff. We noted lots of laughter and chats during activity facilitated by 1 staff member. Staff knew people's non-verbal and behaviour cues, offering reassurance and distraction techniques when needed. During our 30 minutes observation there was only 1 member of staff present in the communal lounge with 12 people. Staff told us the other staff member on duty was supporting people in their bedrooms and another one was on their break. The activities coordinator had been moved to support in the kitchen for the day when we visited. This meant staffing levels were not adequate to meet the needs of people using the service at the time of our on-site visit.

We received mixed feedback from staff about staffing levels. Comments included, “It’s frustrating when poor staffing and lack of cooperation among some team members get in the way of delivering the standard of care, we all want to provide.”

Records showed staff received training appropriate and relevant to their role, and service, with their competency assessed. Training was refreshed at regular intervals to maintain knowledge and skills in line with best practice. However, staff did not always demonstrate competence and understanding as to how to apply their learning into safe practice.

At the time of our inspection none of the care staff had Level 2 or above qualification in health and social care and only 5 out of 8 permanent staff members had completed the Care Certificate, all in their previous employments. The Care Certificate is the minimum training, supervision and assessment that all staff should receive as part of induction and before they start to deliver care. It provides a foundation for health and social care worker roles, ensuring that the new staff can provide a compassionate and safe care.

Relatives expressed concerns about staff lacking training in areas such as people’s dietary needs or safe moving and assisting practices. A relative told us, “There's a small group of nurses and they’re trained. The others fill the gaps. [My loved one] has got bruises several times when they move [them]. I don't think they're all that well trained."

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not follow national guidance in relation to infection control. Premises that the provider was responsible for were not clean and hygienic. Staff received appropriate training on infection prevention and control (IPC) however they did not fully understand their responsibilities in relation to hygiene. This meant people were exposed to risk of acquiring and transmitting infections such as Covid or Norovirus outbreaks leading to health deterioration.

We found some areas of the premises had not been hygienically cleaned including a basin in a shower room. This had been mentioned by the registered manager as needing to be cleaned following a manager’s ‘walkaround’. It was not clear if this had been cleaned since the walkaround report was issued as when we inspected it remained heavily soiled.

Other areas could not be hygienically maintained. For example, in a shower room, flooring had separated from the wall exposing areas that could not be cleaned. Paint had chipped on some door frames, doors and on a bed head and footboard. Exposed, unfinished wood is porous, and bacteria cannot easily be cleaned from it.

IPC audits had not identified our concerns about flooring and chipped paintwork, however had mentioned a lack of toilet paper dispensers. When we inspected, toilet paper rolls were mostly not in dispensers, instead being on the floor, on cisterns or on bin lids.

Housekeeping staff maintained cleaning schedules of completed tasks, however these did not seem to reflect the environment. For example, the lower floor sluice, as with other communally used areas had a cleaning record on display which indicated the room had been cleaned the previous day. We noted the window, sluice machine, and floor were not clean and there were items stored in a cluttered way including personal protective equipment (PPE) like aprons with commode buckets, and commode buckets with bowls to wash people with.

Relatives expressed their concerns about infection prevention and control practices in the service, which put people at increased risk of contracting infectious disease and health deterioration. Comments included, “I’m not confident the cleaner and care staff fully understand cleaning to a standard here or cross contamination. I have found soiled pads placed on furniture area of where my [loved one’s] personal belongings are kept.” Other relatives told us about dried excrements in people’s bedrooms and communal toilets, frequent shortages of toilet paper and paper hand towels, sanitisers and tissues.

Access to support and personal protective equipment for staff was unreliable. Staff expressed their concerns and frustration about lack of resources to enable them to consistently apply good infection control. Comments included, “There is a real lack of supplies and hygiene materials and PPE, wet wipes, napkins and tissues. The lack of the correct buckets and mops to be used for cleaning. We are continuously repetitively requesting them to make sure there are enough."

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider did not always follow relevant national guidelines around storing medicines, giving them to people, and disposing of them. This meant people did not always received their medicines safely and as prescribed. The provider had a medicines policy in place however, it was not always followed. Stock of medicines was not effectively managed, and medicines were not always recorded or administered as prescribed which meant people were at risk of harm of medicines errors occurring and remaining undetected. For example, we identified discrepancies in the stock of 2 strong opioid pain relief medications classified as controlled drugs in the cupboard and stock recorded in the register. One of the controlled drugs had been continuously administered to a person despite being out of date, as per manufacturer’s instruction. This meant the person was at risk of experiencing pain due to pain relief medicine being out of date and less effective.

Medicines were not stored in line with current legislation and guidance. For example, we found insulin for management of diabetes was stored in a designated medicines fridge. The fridge temperatures were recorded daily stating the minimum and maximum temperatures. However, the fridge temperature was not reset by staff as directed by the fridge manufacturer. This was also prompted on the recording form stating in red, ‘Reset Temperature after each reading’. Incorrect storage of insulin such as exposure to high or freezing temperatures can render it less effective or harmful, which meant people were at increased risk of harm.

Relatives expressed their concerns about the management of medicines at the service. A relative told us they had to prompt staff to contact GP and request a stronger opioid-based pain relief medicine for their loved one as what they had prescribed was not efficient to control their pain. Another relative commented, “I don't know the medications given to [my loved one], but [they] tend to spit their tablets out and put them in the urine bottle."