During an assessment under our new approach
Royal care home is a residential care home which provides personal care for up to 27 older people and people living with a dementia. We assessed all quality statements under the five key questions of Safe, Effective, Caring, Responsive and Well Led. We completed an onsite assessment at Royal Care Home on 11, 12 and 15 August 2025.
At our last inspection, we identified breaches of the legal regulations in relation to safe care and treatment, good governance and Deprivation of Liberty Safeguards. At this inspection we found some of these issues had not been fully addressed. At this inspection we found three breaches of the legal regulations in relation to safe care and treatment (in areas including medicines, infection control, risk management and safe environments), good governance, staff supervisions and recruitment.
Some work needed to be done to improve the services learning culture. Improvements were needed to ensure people were protected and kept safe around areas including visitors, the environment and infection control. Staff understood and managed risks, but records relating to risks needed to be improved. The facilities, equipment and environment were not always well-maintained and risks were not always mitigated. There were enough staff with the right skills, qualifications and experience in place, but they had not always been safely recruited. Managers made sure staff received appropriate training, though regular supervisions and appraisals were not taking place. Medicines were not always safely managed. Staff handovers were in place to support sharing of information.
Staff reviewed assessments though these did not always identify issues we found with records. People’s care records were not audited. People always had enough to eat and drink to stay healthy, though records relating to some people’s nutrition were not always accurate. Staff worked with all agencies involved in people’s care for the best outcomes but feedback from professionals was mixed and we found necessary improvements were slow to be implemented. People’s consent was gained where possible and staff took decisions in people’s best interests where they did not have capacity. People were involved in assessments of their needs.
People were treated with kindness and compassion. Staff protected their privacy and dignity and they treated them as individuals and supported their preferences. People had choice in their care and were encouraged to maintain relationships with family and friends, though improvements was needed in areas such as activities. Staff responded to people in a timely way. The service had procedures in place to support staff wellbeing, but staff did not feel they were always being supported equally or fairly.
People were involved in decisions about their care. The service provided information people could understand. People and staff knew how to give feedback, but staff were not always confident this was acted on in a timely way. The service was mostly easy to access. People were involved in planning their care, though some people’s records were not always safely stored.
Staff shared concerns about the management. Leaders were visible and knowledgeable, but not always proactive. Staff felt able to give feedback though they said it was not always acted on promptly. Staff did not feel treated equally. There was poor governance of the service. There was not a culture of continuous improvement within the home based on the concerns identified at this inspection and the fact that some of these were similar to concerns we identified at our last inspection.