Ringway Mews Care Home

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 assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, premises and equipment and staffing.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice.

The provider did not have a robust approach to ensure learning was embedded at all levels. Shortfalls identified at the last inspection had not been resolved. There had been a failure to address the issues at the last inspection despite a request to outline how they would respond to the breaches in an action plan.

The manager was open and transparent and had improved oversight of accidents and incidents. Further improvement was needed. Systems and processes had not been fully developed to ensure all incidents were responded to appropriately. This included updating care plans after incidents to ensure learning was shared.

The manager had improved how the home worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Care plans were not to the required standard to support safe pathways and transitions.

We had concerns about the accuracy of care records as care plans were not always updated and records were not always complete; we could therefore not always be assured staff would have the correct information to share with external partners.

We received mixed responses from external professionals. Three indicated further improvement was still needed. They told us, “Agency staff can provide a various number of difficulties with regards them knowing the patients and handing over necessary information to help us formulate our assessment” and “Lack of or delayed escalation to health professionals appears to be an issue. I have recently had two families report that they had to ask staff to request a GP.”

One key external health professional who worked regularly with the home reported significant improvements since the last inspection. They told us, “This has improved considerably. The communication on all the units to the clinical team has improved and staff are escalating concerns in a much more timely and safe manner but also there is now a greater understanding regardinga proactive approach and utilising care home rounds more effectively. The staff at the home are much more organised too and have gained a greater understanding of escalating clinical concerns but also proactively requesting advance care planning, medication reviews etc…”

Systems for identifying and reporting safeguarding concerns were not effective. The provider did not always share concerns quickly and appropriately.

The provider did not fully understand their responsibilities. We identified several safeguarding referrals that had not been notified to CQC as required. These were all submitted during the assessment. External professionals also expressed concerns. Thery told us, “Obtaining information for safeguarding enquiries can be difficult and delayed which can impact how quickly concerns are explored and resolved.”

Staff were supported through induction and training to understand their safeguarding responsibilities. We discussed safeguarding with staff and checked their learning in practice. They understood how to recognise signs of abuse and when to report concerns. It was not clear from the records if care plans were updated post incident or if learning had been implemented to prevent incidents from being repeated.

A high proportion of staff we spoke with shared concerns about the impact of low staffing on safety. They told us, “Our dementia unit can be particularly challenging because some residents display distressed or aggressive behaviours, and there are often not enough staff available to manage situations safely and calmly” and “Staffing levels, especially during night shifts, are a significant concern. There are often only 2 staff members on the floor caring for around 30 residents. This creates pressure on staff and can make it difficult to respond promptly to residents’ needs, provide adequate supervision, and complete care tasks safely and effectively.”

Relatives also shared concerns about the impact of staffing levels. They told us, “The regular staff are lovely, and [relative] has formed real bonds with them…There just aren’t enough staff, especially at weekends. If someone needs changing, it takes 2 staff, meaning the rest aren’t being watched for quite long periods sometimes, which is unacceptable..."

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. Incare homes, thiscan be donethrough a procedurecalled the Deprivation of Liberty Safeguards (DoLS),whichispart of the Mental Capacity Act 2005(MCA).We checked whether the service was working within the principles of the MCAand how they managed DoLS within the service.

Staff received training in the Mental Capacity Act. This supported them to uphold people’s rights.

The provider did not work well with people to understand and manage risks.

Risk assessments were not always in place and those that were, were not always person-centred and regularly reviewed with the person or their representative.

Shortfalls related to choking risks and thickeners identified at the last inspection had not been addressed. Adequate risk assessments were still not in place for people at risk of choking and where people required thickened fluids, it was not always clearly documented when this had been provided. In addition, we found a variation in practice across different units where it was unclear who should be signing when the thickener was administered. Care plans were not always updated when people’s needs changed, and we were therefore not confident individuals consistently received the correct modified diet.

Shortfalls identified at the last inspection in relation to falls management and skin integrity had not been addressed. The electronic care planning system did not always demonstrate when people had been supported to re-position by staff in order to give them adequate pressure relief. In addition, people were still at an increased risk of falls related injuries as people were not wearing appropriate footwear which could increase the risk of falls. Staff said these people often refused to wear appropriate footwear, although this information was still not clearly recorded in their care plan.

When people communicated their needs, emotions or distress, people did not receive consistent person-centred support. There were not enough staff to manage this risk in a positive way that protected people’s rights and dignity.

The provider detected and controlled potential risks in the care environment. Systems were in place to monitor equipment, facilities and technology to help deliver safe care.

Regular maintenance checks of the premises were completed to ensure safety requirements were met. Safety certificates were up to date, and any recommended actions had been addressed. This included gas safety, fire safety, and legionella.

Several staff members raised concerns with us about the availability of equipment on Halifax unit. They told us, “There is insufficient equipment such as hoist, weighing hoist, dishwasher. The dishwasher has been faulty for a while without replacement, especially in a high- demand unit, which has relatively impacted both residents and staff” and “There are also shortages of equipment and resources which impact daily care. For example: The unit is currently operating with only one full-body hoist when previously there were two available. There are not enough plastic beakers to encourage residents’ fluid intake that is already being reported. There are shortages of plates and kitchen utensils.” We raised this with the manager and were told new equipment had been ordered including a dishwasher.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

More senior staff were needed to support the improvements required in the home. The home was short of one deputy clinical lead and one unit manager. More regular and consistent support was also needed from regional managers to support the manager.

Inspector observations and feedback from staff highlighted concerns about the impact of poor staffing levels in the home. A high proportion of staff we spoke with expressed concerns about staffing levels. They told us, “At times there are up to 16 residents in the lounge, most times between 12-16 residents will be there, meaning that once the nurse is out in the corridors giving medicine and staff start to assist residents to bed, there is no way to supervise all the other residents in the lounge” and “We are also relying heavily on agency staff. Many agency staff do not know the residents well, and some are inexperienced in dementia care, which increases pressure on permanent staff who must manage resident care, support agency staff, and complete documentation at the same time.”

A number of relatives we spoke with expressed concerns about staffing levels. They told us, “It isn’t the best care home, and it isn’t the worst. They need more staff. Sometimes, it doesn’t seem a safe ratio. They also use a lot of agency staff. They just need to recruit more" and “No, there’s not enough staff and the ones who are there are run ragged. It’s not their fault, it’s not neglect, it’s just not enough staff as dementia patients can be demanding.”

The use of agency nurses had reduced by half in the last 6 months, and the manager had successfully recruited new nurses.

Training and support for staff had been identified by the provider as an area for improvement prior to the assessment. More face-to-face training was being provided. However, we were told this would take a long time to roll out leaving staff without sufficient training. Staff told us they needed more dementia training, more challenging behaviour training and more training to use the electronic care plans.

Staff were recruited safely and had the appropriate pre-employment checks in place before employment commenced.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The home had been inspected by the local authority infection control team in January 2026 and scored 90% and the relatives we spoke with were generally positive about the cleanliness of the environment.

Inspector’s observations on different days did not match this experience. In two units in particular the premises and equipment were not clean and hygienic.

Domestic staff followed cleaning schedules and staff received training and understood their infection control responsibilities.

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

Staff did not always store medicines safely and securely. They did not consistently record the temperature for the medicine’s fridge meaning we could not be assured the medicines were safe to use. Controlled drugs were stored securely and accurate records were kept.

Electronic medication administration records (eMAR) were not always completed appropriately. People consistently did not receive their medicines at the prescribed times, including time-critical medicines. Records showed that people regularly received their medicines late. This included important medicines such as antihypertensives and dementia treatments. Staff also recorded frequent missed or refused doses without clear escalation or follow-up. There was a lack of effective oversight which increased the risk that people did not receive medicines safely or as intended, leading to poor health outcomes.

Chronic conditions such as diabetes were not well managed in individuals requiring enhanced or further monitoring.

The service did not have adequate written guidance for ‘when required’ (PRN) medicines. Where protocols existed, they did not give clear, person-centred guidance on how to meet individual needs.

Care plans were not detailed, accurate, or person-centred. They included limited information about medicines, side effects and how to administer them safely. Staff recognised that care plans were still in progress, but many continued to be outdated or incorrect and there was not a plan in place to action the updates needed.

Care plans did not provide clear guidance on key areas such as diabetes management, blood glucose monitoring, hypertension, or topical treatments for pain management. Some people needed thickened fluids to reduce the risk of choking. However, records did not show that staff used thickeners consistently or correctly, which put people at risk of harm.

Audits on medicines including MAR charts had not been effective at identifying the issues found during the inspection.