Archived: Lyme Regis Care Home with Nursing

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.

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

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to management’s oversight and governance at the service.

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The registered manager had shaped the culture by engaging with staff, people who use services, carers and other stakeholders. However, shared vision and strategy were not fully enshrined within the service or understood by all staff. For example, staff did not always demonstrate a good understanding of the service’s vision, values and strategic goals. The provider could not assure themselves staff at all levels had a well-developed understanding of human rights, and they always prioritised safe, high-quality care. Leaders and staff did not always share an understanding of the risks and issues facing the service.

All staff felt significant improvements were made since the registered manager commenced in post. However, some staff told us they felt leaders were inconsistent in promoting a culture of collaboration, where people and staff are listened to and communicated with to help promote learning and improvement. Comments from staff included: “This service has potential, especially with a strong manager like [manager’s name]. But if real improvements aren’t made, particularly in staffing levels and building a culture of teamwork the risk of burnout and compromised care will continue. [Manager’s name] leadership deserves to be matched by better resources and a more supportive environment.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We received overwhelmingly positive feedback from staff about the registered manager. Staff told us they are approachable, supportive and lead by example. Comments included, “[Manager’s name] has bought a quiet strength and stability to the home. I find [them] professional and a positive role model for the staff and I admire [their] integrity.”

The provider did not have a fully supported management structure in place. The registered manager told us they not always felt supported by the provider. They told us, “When I first started, the directors would contact me over the phone often, then weekly and then fortnightly. I have all my one-to-ones over the phone. They had an external contractor to support the service with compliance and quality assurance but that just stopped few months ago.”

Leaders at every level were not always knowledgeable about issues and priorities for the quality of the services provided. Leaders were not always aware of their own limitations and did not always access support and independent scrutiny when required. Although the managers had a good understanding of CQC requirements, in particular, to notify us, and where appropriate the local safeguarding team, of incidents including potential safeguarding issues, disruption to the service and serious injury, this knowledge had not always been applied into practice.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had ‘Freedom to Speak Up’ and ‘Whistleblowing’ policy in place and procedures for staff to actively raise concerns, which were effectively embedded. Staff survey and team meeting minutes evidenced staff have been given the opportunity to speak up and drive improvement. There was also evidence of action taken in response to feedback from staff. Leaders were open to feedback and staff felt supported and encouraged to speak up and raise concerns about quality of care.

Staff were aware of how to raise a concern both internally and externally. Staff told us: “The management provides open door policy to staff. There is also protocol for whistleblowers in the home policy.” Results of staff survey completed by the provider in September 2024 confirmed all staff knew how to report concerns about quality of care.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had policies and procedures supporting diversity and inclusion within the service and promoting diversity and inclusion in the workforce. Staff in various roles withing the home were from diverse backgrounds. However, we observed lack of diversity within the care staff team. All care staff were from overseas and no local staff was employed to deliver personal care at the time of our inspection. Staff told us they would care for anyone if they needed it, regardless of their background. Staff received training in equality, diversity and inclusion; completion rate was 100% when we visited.

Leaders did not always support working towards an inclusive and fair culture by improving equality and equity in the team and ensuring equality of opportunity and experience for the workforce within their place of work. Staff and leaders always demonstrated good understanding of the Equality Act. We received mixed feedback from staff about diversity and inclusion within the team. Comments included, “I’ve seen many people come in for interviews. They seemed well qualified for the job they applied for, but I never see them taken on. It appears to be all family run or within a close circle. It worries me considerably” and “I believe that employment of staff is done through an agency, and I find it odd that hardly any of the staff are local employed. I do think it's a very closed culture here as staff arrive always the same background.”

The registered manager told us, “We struggle to retain care staff that are local. They resign after few shifts, they don’t stay.”

Relatives commented, “We have not noticed many changes to staff recently. Now the majority of the staff remain the same. They’re all from [2 geographical locations overseas].”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance, management and accountability arrangements were not always reliable and inconsistent. Management systems were not effective and did not identify or manage risks to the quality of the service found at this inspection. Systems were not regularly reviewed. Systems for identifying, capturing and managing organisational risks and issues were inconsistent and not all legal requirements were fully understood by leaders. For example, the provider’s policy and procedure for legionella identified the registered manager to be a technically competent person to assess the risks arising from exposure to legionella because of the water system. However, the provider did not have current risk assessment for water hygiene management and no schematics on the premises confirming the water system was safe. This meant people were at risk of harm from water born infections such as Legionnaire’s disease.

Quality assurance systems did not operate effectively in helping to ensure people consistently received safe and good quality care and support. Various audits completed at provider level by the management and during regular director’s visit conducted at the service had not identified the shortfalls found within the inspection. For example, quarterly audits of recruitment / staff files were ineffective and did not identify concerns around recruitment processes found at this inspection. Audits did not identify gaps in employment history provided by staff during recruitment process or staff references that were missing or had not appeared genuine but had not been verified. This meant people were at increased risk of being supported by staff that were not recruited safely or were suitable to work with vulnerable people.

When the provider’s quality assurance processes identified issues, this had not led to improvements and risk mitigation measures were either not implemented or were ineffective. For example, we reviewed ‘Manager Walk Around’ and ‘Spot check’ reports which identified repeated issues in relation to malodorous and visibly unclean sluice rooms, which were left open, unsecured and accessible to people. During our inspection on 22 July 2025, we found theshortfalls remained; the lower floor sluice room was unsecured, visibly unclean and malodorous. This placed service users at increased risk of avoidable harm through the spread of infection.

Roles, responsibilities and accountability arrangements were not always clear. Not all staff understood their role and responsibilities. Staff performance relating to unsafe care was not always recognised and responded to appropriately and quickly. Staff were not always given honest feedback about how they were performing, and where improvement was needed. None of the registered nurses working at Lyme Regis Care Home with Nursing were directly employed by the provider and had their employment contract with an external agency. A large proportion of care staff were also employed by the external agency and did not have a permanent employment contract with the provider. Processes in place to ensure staff accountability for recording and reporting incidents or escalating concerns relating to health and safety were not effective. Poor staff performance was not always recognised or consistently responded to, and people were at risk of harm as a result.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service was not fully embedded in the community, and no consistent efforts were made by the provider to foster positive relationship with local community and collaborative partnership working. Staff and leaders did not always engage with people, communities, and partners to share learning with each other that resulted in continuous improvements to the service. These networks were not always used to identify new or innovative ideas that could lead to better outcomes for people, and the manager recognised the need for more collaborative partnership working to drive improvements.

We received mixed feedback from partners about collaboration and joined up working with the service. Partners commented on levels of staff training, staffing shortages and the leadership structure which resulted in poor communication and collaboration. Comments included, “Our experience has mostly been positive, but communication can be inconsistent at times. I do think the staff try hard to maintain a good service, but maybe due to staffing levels / training they can fall short on organisational matters. These issues seem largely tied to staffing shortages and time constraints.”

We received mixed feedback from the relatives about the management and leadership. Relatives felt management of the service was inconsistent and did not always effectively guide their team to deliver safe and compassionate care. Some relatives told us they noticed recent improvements. Comments included, “The management is inconsistent. Could be better. I’ve noted some improvements over the past few months and hope that it is sustained."

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Quality assurance arrangements were not always effective and applied consistently. The service was not effectively monitored to ensure continued learning and improvements. Concerns were investigated and lessons were shared and acted on. However, some investigations lacked the full rigour needed and the learning was not always applied inconsistently.

Staff and leaders had not consistently demonstrated a good understanding of how to make improvement happen. The approach was inconsistent and had not always included measuring outcomes and impact. There were processes to ensure that learning happened when things went wrong, and from examples of good practice however they were not always effective.

Improvements were not always identified, and where they were, action was not always taken and identified shortfalls were not always rectified in a timely way and lessons learnt had not always been effectively shared with all staff to prevent re-occurrence. Improvements were not fully embedded and sustained in practice. For example, we found staff lacked full understanding and awareness of how to support people with their oral health needs despite receiving training and supervision in this area. This had placed people at risk of not having all their care needs met and risks of oral health deterioration which can lead to serious infections or even sepsis.

Staff and leaders had not always demonstrated a good understanding of how to make improvements happen. The approach was inconsistent and had not always included measuring outcomes and impact. There were processes to ensure that learning happened when things went wrong, and from examples of good practice however they were not always effective.