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. At our last assessment we rated this key question requires improvement. The service had been in breach of legal regulations in relation to management oversight and governance at the service. The service had made improvements however remains in breach of regulations. At this assessment the rating has remained 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 a lack of clear oversight of the service and its governance, and a failure to monitor and improve shortfalls causing previous breaches in regulations 12 and 17.

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.

Since our last inspection there had been multiple changes to the management team. A new manager was now in post, however there had not been strong leadership and though the manager was making positive changes as yet there was no clear vision for the future. Work to strengthen leadership and vision was ongoing.

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.

Since our last inspection there had been changes to the management team as mentioned in the previous section. Feedback from people and relatives was positive about the latest manager, they had spent time with people and staff getting to know them and learning where change was needed in the service. However, not all people and relatives knew there had been a change in manager, this had not been communicated well to everyone. The manager had applied to become registered with the CQC.

The provider was recruiting to a deputy manager post and a compliance manager and consultant were also involved in managing both the day to day running of the service and the required improvements. The management team was in transition and work was underway to strengthen leadership capacity and communication.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 staff team at Lyme Regis Care Home were almost all overseas recruits. Staff were supported through supervision sessions with their line managers however, we saw records showing each staff member had just 1 formal supervision meeting in the last year. We received just 1 response to a request for emailed feedback from staff so are not able to say if staff felt included in the culture of the service.
The provider told us supervision did in fact take place more frequently than records reflected, and they are working to improve record keeping, and to engage more with staff.

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.

There was not a clear governance system when we inspected, however following the inspection, a compliance manager had started in post and a deputy manager role was being recruited to. In addition, a compliance consultant was also supporting the service.

The provider had recently introduced an electronic auditing system to take the place of the paper based system. The system should, according to the provider, give clearer and more effective oversight of the service. This was at the early stages of implementation and still embedding into practice but was part of work completed by the provider to improve governance systems.

Audits we reviewed did not always reflect our findings. Maintenance audits noted radiator cabinets to be secured to walls that we found were not attached. The quiet lounge, when checked the day before our inspection did not note the excess of stored furniture.

‘Daily Walk Round’ checks were completed by a registered nurse or a member of the management team. These were completed twice daily and should identify shortfalls in service delivery and the environment. These were dated but times not recorded so it was not easy to judge the importance of what is noted. For example, if staff were not interacting respectfully with people or there were no activities taking place, during the night this would not be a problem but during the day it would. Similarly, if a person’s door were propped open this was a problem, however during the day there are people and staff present and awake should the fire alarm sound but a fire door propped open during the night while people sleep when there are only 3 staff present has much more serious potential impact.

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.

NOT REVIEWED

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.

Improvements were not always noted and actions taken to address them. For example, following our last inspection, repairs were done to some radiator cabinets and some pipework was boxed in for safety purposes. At this inspection we saw radiator cabinets in need of repair and pipework than needed to be risk assessed and possibly boxed in. Learning was not taken from the previous inspection.
We were not confident the audit systems in place were identifying shortfalls and that actions were taken to address them. While some learning had taken place, opportunities for learning were not always used. Further work is underway to strengthen learning and audit systems.