Royal Leamington Spa Nursing Home

Ratings

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Good

• Responsive

  Requires improvement

• Well-led

  Requires improvement

Our view of the service

Date of inspection: 20 April 2026 to 23 April 2026.

Royal Leamington Spa Nursing Home is a nursing home providing care to younger and older people who may be living with a dementia or physical disabilities. It is registered to provide care for up to 43 people. At the time of our inspection there were 41 people living at the home. Care and support are provided across 3 floors in an adapted building which consisted of 2 buildings linked together.

This inspection was undertaken as an aged rating, and we reviewed all 5 key questions under our single assessment framework. The last comprehensive inspection of the service was in 2019, where the service was rated as Good. At this inspection, we found legal breaches of regulations around the safety of the environment and good governance. We sought immediate assurances from the provider as to actions taken to significantly improve the safety and service people received. In instances where the Care Quality Commission (CQC) have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.

The provider’s quality assurance systems were ineffective in monitoring risks to people’s safety. This included a lack of effective checks of the environment and fire safety. Where maintenance checks, or health and safety checks were carried out, these were completed by staff who did not have the right knowledge, experience or training. Where checks were completed by the registered manager, these were not recorded. The registered manager failed to give us any evidence of audits or checks, completed by them, which may have identified the concerns we found during our visit.

Environmental checks had failed to detect and address safety deficiencies within the physical environment and in relation to fire safety. This included risks of people accessing hazardous materials and liquids and a lack of security measures to keep people safe. During our inspection we identified significant fire safety concerns, and we made an urgent referral to the fire service. The fire service subsequently took enforcement action.

Care records and risk assessments were completed and reviewed, however the provider’s governance systems did not ensure that identified risks were managed safely in practice. For example, pressure relieving mattresses were not always set correctly to ensure risks to people’s skin integrity were effectively managed. This meant the provider and registered manager could not be assured that people at risk of pressure damage were receiving appropriate care to prevent skin breakdown. We also found thickening agents prescribed to reduce the risk of choking were not stored securely. These were routinely left accessible in people’s bedrooms. There were no effective systems in place to monitor safe storage, which placed people at risk of choking or aspiration if ingested.

The issues we found at this inspection visit had not been identified by the registered manager or provider. We could not be confident, people received safe care in an environment that kept them safe. There was limited evidence of an effective and robust quality assurance system to manage people’s care records. Part of the providers quality checks was a ‘resident of the day’ which was a process to review the care people received. We found those reviews had not always identified where improvements were required.

Staff told us they received training relevant to their roles to keep their skills and practice updated. Staff told us communication was good and they felt supported and valued in their roles. Staff teams worked together well and in conjunction with other healthcare professionals. The registered manager told us they were proud of the person-led values in the home and the relationships they fostered with people and their relatives.

People's experience of this service

Overall, people told us they were happy with the care they received. People told us staff knew them well, treated them kindly and supported them in a respectful manner. During the inspection we observed some warm and positive interactions between staff and people living in the home. People spoke positively about the food provided. Meals were described as enjoyable, and staff made special arrangements for those with dietary needs, including allergies, diabetes or vegetarian preferences.

However, information was not always accessible in formats suitable for people’s needs. For example, weekly activity schedules were written on a board on the ground floor, meaning people who spent time in their rooms were unable to see what was planned. Some people told us staff verbally informed them of activities, but this was not consistent.

Visitors were welcomed into the home and encouraged to continue supporting their loved ones. Relatives told us they felt involved in their family member’s care and were kept informed when changes occurred. However, they were not routinely involved in care planning, and when changes were made within the home, the reasons for these were not always clearly communicated to people or their relatives.