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. At our last inspection we rated this key question requires improvement. The service was in breach of legal regulations in relation to safe care and treatment, safe and effective staffing, safe environments and the ways people’s medicines were managed. The service has made improvements however remains in breach of regulations. At this assessment the rating has remained requires improvement.

The service is in breach of regulations in relation to assessing the risk of, and preventing, detecting and controlling the spread of, infections, fire safety, a lack of a dementia friendly environment, safe storage, and ensuring premises used by people is safe.

This service scored 41 (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 processes in place to record accidents and incidents and to escalate to healthcare services where required. However, records did not always demonstrate consistent categorisation and documentation of safety events. We found conflicting information about whether some occurrences were recorded as an accident or an incident, including examples of falls recorded differently. This could limit the provider’s ability to identify themes and patterns and reduce the risk of recurrence.

We also found variation in the level of detail recorded, which could impact effective oversight and analysis to mitigate future risks and share learning. For example, a record of a significant event that required an ambulance response did not include sufficient detail of the injury sustained and/or staff actions, whereas some minor/no‑injury events contained more detailed post‑event accounts. This lack of consistency could result in potentially significant learning being missed.

The provider did not always ensure that care planning and monitoring supported continuity of care, particularly following admission or changes in people’s needs.

Prior to admission, people’s needs were assessed, and care plans were reviewed on admission to ensure staff had access to relevant information. However, we found that for a person admitted shortly before the inspection, care plans were not updated in a timely way to reflect new and emerging needs identified following admission. The person was known to feel anxious and require increased reassurance, particularly at night, and needed more frequent support. Despite this, their care plan was not adjusted and staff continued to check on them every four hours, leaving them alone for extended periods while feeling anxious and potentially needing care support.

This demonstrated that, while assessments and reviews took place, care plans were not always sufficiently dynamic to reflect changes in need promptly, which could impact people’s safety and continuity of care.

The provider did not always work effectively with all relevant partners to ensure safeguarding concerns were shared appropriately.

When abuse was suspected, the provider raised safeguarding alerts with the local authority safeguarding team, and records showed that safeguarding concerns were investigated with measures put in place to reduce the risk of reoccurrence. Staff told us they were able to raise concerns with the management team, and the provider had oversight of safeguarding within the service.

However, we found that the provider had not consistently submitted statutory notifications to CQC in relation to alleged and actual abuse, as required. Providers must notify CQC of certain events so that we can effectively carry out our regulatory function. This meant concerns were not always shared appropriately with the regulator.

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

The provider did not assure us they were aware of or had mitigated risks. We found some risk assessments had not been fully completed. These inform the development of care plans and for a person, were not sufficient to ensure their needs were being safely met. For example, the risk assessment and care plan for the person held conflicting information. One stated they were independently mobile, the other that they needed support from 1 staff member and a walking aid. The risk assessment was only partly completed.
Risk assessments and care plans should be compiled with people and relatives as far as is possible. This enables a more holistic approach to be taken to support people with managing risks in a person-centred way. However, not all relatives and people were aware of risk assessments and care plans. One relative told us, “No. I did speak to [manager] and I said, ‘what are you doing in the way of care for them?’ Medication, keeping her safe, clean and eating?”

The provider did not always detect and control potential risks in the care environment or ensure that equipment and facilities supported the delivery of safe care.

At our previous inspection we identified shortfalls in relation to environmental safety. While some improvements had been made and a programme of works was underway at the time of this inspection, further action was required to protect people from avoidable harm. We identified unsecured or freestanding radiators accessible to people, radiator covers that were not always secured, and weekly maintenance checks not being completed in line with the provider’s risk assessment. Additional risks included furniture at risk of tipping and protruding pipework that had not been risk assessed.

We also identified fire safety concerns, including damaged or poorly fitted fire doors and batteries being charged in confined spaces alongside combustible materials. Although contractor‑led works were ongoing at the time of inspection, these risks remained present. We shared our concerns with the local fire service, who subsequently attended to assess the premises.

In addition, maintenance was not always completed to an appropriate standard. For example, a fire door had been repaired using glue without an assessment of how this would impact its performance in the event of a fire. Improvements to the premises were ongoing, including roof repairs following water ingress at the time of our visit.

The provider did not always provide sufficient assurance that staffing arrangements, supervision, and team working consistently supported safe care that met people’s individual needs.

Staffing levels were set using a dependency tool that was reviewed regularly. When we inspected, there was 1 registered nurse and 5 care assistants on duty in the morning, 1 registered nurse and 4 care assistants in the afternoon, reducing to 1 registered nurse and 2 care assistants at night, supporting 27 people.

However, we found inconsistencies between management accounts and care records in relation to night‑time checks. While the manager told us that checks were completed hourly at night, care records consistently showed checks were completed every four hours. This limited assurance that care was being delivered as intended.

We were also told that staff living in accommodation adjacent to the service could be called upon to support emergency evacuation at night. However, the provider was unable at the time of inspection to confirm whether this was a formal requirement or how availability was assured, which limited assurance regarding emergency contingency planning.

Although recruitment processes had improved since the previous inspection and were compliant at the time of this inspection, supervision and support processes were not always consistently evidenced, which could impact assurance that staff were effectively supported to deliver safe care.

The provider did not always effectively assess and manage the risk of infection or ensure that infection prevention and control measures were implemented consistently across the service.

We identified multiple environmental and practice‑related IPC risks during the inspection. These included chipped and damaged surfaces that could not be effectively cleaned; damaged furniture with rips and tears; unhygienic storage of personal care items, including a toothbrush stored in a visibly unclean cup and disposable razors not being disposed of; and inappropriate storage and segregation of laundry, including clean items being placed alongside red bags of soiled laundry.

Areas of the service were visibly unclean, including dust, mould, and malodours in communal and private areas, and items such as clean linen being stored on the floor. Toilets and bathrooms did not consistently have toilet roll holders, resulting in toilet rolls being stored on floors, pipes, and cisterns, increasing the risk of contamination.

Although the registered manager had taken steps to address some concerns, including work to address malodours, these had not been completed without delay. While IPC processes were in place, these findings demonstrated that infection risks were not consistently detected or controlled at the time of inspection.

The provider did not always ensure that medicines and treatments were managed safely and consistently in line with people’s needs, capacities and preferences.

People usually received their medicines safely as prescribed, staff were knowledgeable about people’s needs, and nurses received regular training and competency checks. Systems were in place for ordering, storage and disposal of medicines, including those requiring refrigeration or additional security.

However, we identified inconsistencies that limited assurance. Some person‑centred ‘when required’ (PRN) protocols were not available with people’s medicines records, and variable doses were not always recorded. Risk assessments were in place for some higher‑risk medicines, such as flammable topical preparations, but were not consistently in place for others, including anticoagulant blood‑thinning medicines.

We also found a prescribed emollient in use with the person’s name removed and being used for another resident, which was disposed of when identified, and no incident form had been completed. Some topical preparations did not have dates of opening recorded. While issues were addressed at the time, medicines audits had not identified all of these concerns prior to our visit.