Royal Leamington Spa Nursing 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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the safety of the environment.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

In 2023 the provider received an enforcement notice from the fire service due to concerns around fire safety. This was signed off in 2024 with the recommendation that their fire risk assessment was reviewed regularly and when any changes to the building were made. Despite the seriousness of this notice, we found little had been learnt by the provider and the fire risk assessment had not been reviewed during improvement works to the building. An up-to-date fire risk assessment may have identified some of the fire safety issues we found, and ensured the building was safer for people.

The registered manager told us they reviewed incidents, falls, weight changes and safeguarding concerns on a case‑by‑case basis. However, there was no documented evidence that this took place or that information was analysed to identify themes, patterns or emerging risks across the service. This meant opportunities for organisational learning were missed, and the provider could not be assured actions taken were effective, consistent, or informed by wider trends. This limited the provider’s ability to drive improvement, prevent recurrence, and maintain a proactive learning culture.

Staff had previously benefited from focused ‘thematic’ supervisions that supported their development and helped embed good practice. However, following a review of practices, the registered manager advised supervisions were no longer themed in the same way. This reduced opportunities to monitor staff competence and promote a culture of continuous learning and improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider’s electronic records system included a ‘hospital passport ‘for each person. This contained important information so if a person required external medical treatment, a summary of their communication, health, mobility and medical needs could be shared. Where people had indicated the level of care they wished to receive in the event of an emergency health situation, this was included in the information shared.

A visiting health professional told us they had no concerns about the care people received. They told us they visited as part of a weekly ward round, and they felt any referrals to them were timely and staff were good at following advice.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff knew what to do to protect people from abuse or poor practice. Staff said they had safeguarding training, knew who to contact if they had any concerns and felt confident to do so. A staff member told us, “I would report it to CQC or the police and make sure the person was safe. It’s not acceptable but I haven’t seen anything.” The registered manager understood what incidents needed to be raised as safeguarding concerns and reported to the local authority and to us.

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called The Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act (MCA) 2005. We checked how the provider managed DoLS within the home. Where people had restrictions in their care plans that they had been assessed as not having the capacity to consent to, the provider ensured DoLS applications had been submitted to the relevant supervising body.

Whilst staff had received training in the Mental Capacity Act, not all staff were able to tell us which people had an approved DoLS, or what this meant for people if they did. However, they told us they would seek advice from the registered manager before imposing restrictions on a person.

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.

People’s health risks were not managed safely. For example, some people identified as at high risk of developing skin damage had pressure relieving mattresses on their beds. Processes were not in place to ensure pressure relieving mattresses were on the correct setting for people’s weights. One person’s weight was 49kg, yet their pressure relieving mattress setting was 170 kg. Another person with the same type of mattress weighed 60kg, yet the mattress was set to 200kg. A failure to monitor this put people at increased risk of sustaining skin damage.

Another person needed a pressure relieving mattress to manage an existing pressure area. We saw the fault and ‘service’ light was displayed on their mattress pump. Staff had checked this mattress on the day of our inspection, and recorded ‘mattress functioning correctly’, which it was not. One staff member said, “We report these issues to maintenance, but I never noticed this.”

People’s Emergency Evacuation Plans (PEEPS) are a record that instructs staff what support people would need to evacuate in the event of a fire. These were not kept up to date and did not always contain accurate information. For 1 person, their PEEPS instructed staff not to attempt evacuation which is unsafe and not appropriate.

We also found inconsistencies in the management of equipment‑related risks. Several people required bedrails to prevent falls. Some bedrail risk assessments stated that bumpers were needed, yet these were not in place. Staff told us that bumpers were not required for one person, despite the risk assessment stating otherwise. This showed that assessments were not always accurate or reflective of current practice

Where people had their fluids thickened to limit their risks of choking, thickening agents were not stored safely. Thickening agents pose a risk of choking and aspiration if ingested and should be kept locked away. Staff we spoke with said they were aware of this but failed to do so. Two staff told us they could not find any keys to lock the thickener away, so it was left on the side in people’s bedrooms. We raised these concerns with the registered manager who was not aware of these issues.

These findings reflected a wider failure of the provider’s systems to ensure risks were consistently understood, monitored and managed. There was no effective oversight to ensure staff followed required safety controls.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We found fire safety and health and safety issues in the home which had not been identified by the provider’s audits and checks. For example, our observations in this home identified several concerns that had potential to compromise people’s safety. We found an exposed mains gas pipe located at ceiling level in a person’s bedroom. Large, bulky and electrical items were stored on top of a wardrobe, directly underneath this gas pipe. This posed an immediate risk to people’s safety if the pipe was knocked, damaged or broken. An upstairs bedroom was being refurbished, yet there was no barrier or lock to stop people accessing this room which contained exposed wiring and sharp tools. The flooring in this room was not adequate to prevent or stop the spread of fire and was immediately located above the kitchen.

We found free standing wardrobes in most people’s bedrooms were not secured to the wall. Wardrobes falling over in care homes pose a significant safety risk to people, particularly those with mobility issues or cognitive impairments. To mitigate this danger, care homes should ensure all freestanding wardrobes are properly secured to walls. Following our second visit, the registered manager had fixed wardrobes to the walls.

Bedrooms on all floors did not have the correct type of window restrictor. Most of the windows did not have an adequate window restrictor that would withstand force to prevent people from accidently falling from height or purposefully absconding. We found some wooden windows and windowsills were in a poor condition so we could not be confident the windows themselves would withstand the forces required to maintain people’s safety, with or without restrictors. In some cases, windows opened upwards (sash) and we saw 1 held open by a block of wood. This put people at risk of injury or entrapment if they opened the window for fresh air.

A lack of security within the home exposed people to the risk of harm. A ground floor fire exit door was left unlocked, meaning people could abscond. We found 1 fire door did not close into the door jamb meaning the spread of fire may not be contained for the legal timeframe. Other doors marked ‘Keep locked’ were left open. We accessed through some of these doors and found hazardous chemicals which, if ingested, could cause harm. We spoke with staff who said, “These doors are usually closed.” We found them open throughout the first day of our inspection.

A lack of robust checks meant some important safety issues went unknown and unnoticed. For example, the temperature of the hot water in a communal toilet exceeded safe limits despite being checked. Due to our significant concerns about the ongoing safety of the premises, we asked the provider to give us written assurance they would rectify these issues without delay.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us there were enough staff to meet their needs, and that staff generally came quickly when they asked for help. During our inspection, we saw staff responding promptly to call bells and leaders monitoring response times to make sure people were not left waiting. Following our feedback, and the identified risks around fire safety, the provider increased staffing at night time to ensure the safety of people if an emergency evacuation was required.

Staff told us staffing levels had improved and that they had enough time to support people. The home also employed housekeeping, maintenance, kitchen and activity staff, which meant care staff could focus on providing direct care. Staff completed training to maintain their skills and support their practice through a mix of face‑to‑face sessions and e‑learning.

The provider used safe recruitment checks that were completed prior to staff starting with the service. Recruitment checks included staff identity checks, references and Disclosure and Barring Service (DBS) checks. DBS checks provide information about convictions and cautions held on the Police National Computer. This helps providers make safe recruitment decisions. Where we found some gaps in recruitment checks, for example no DBS for 1 staff member who had lived overseas prior to commencing work, they were quickly sought by the provider to ensure compliance around recruitment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some skirting boards, door frames and doors had chipped paint and needed redecoration. This made these areas difficult to keep clean to minimise cross infection risks. In 1 example, we saw a person’s ensuite had slatted wardrobe style doors. These doors may not be easy to clean to minimise the risk of infection or to prevent the risk of airborne particles that could cause cross infection risks.

One person received their nutrition through a Percutaneous Endoscopic Gastrostomy tube (PEG). We found formulas were stored in boxes on the floor. Syringes and pumps used for PEG feeding were stored while still wet on both days of our inspection. When equipment is left damp, it creates ideal conditions for bacteria to grow. This increases the risk of infection for people who rely on this equipment. Infection control audits were completed monthly and recent audits had all scored 100%. This meant we could not be assured that the audit was effective in identifying and monitoring risks.

People told us they felt the home was clean and had no concerns around cleanliness. One person said, “They vacuum everywhere, every day, they wipe clean and dust, they wash the carpets once a month, every month, they clean the windows, everything. They have a good housekeeping team.”

We saw some positive practices to minimise cross infection. Handwashing signage was displayed in some toilet/bathroom areas and personal protective equipment (PPE) stations were near bathrooms and were stocked. Staff were seen to use the appropriate PPE at the required times, such as supporting with personal care and at mealtimes.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We could not be confident that people always received their medicines safely or as prescribed.

When we checked how medicines were stored, we found several concerns. Eye drops for 1 person, were not stored in the fridge in accordance with the manufacturer’s instructions, prior to opening. We found unopened liquid nutritional supplements stored in a cupboard outside a person’s bedroom. Some of these were out of date and had not been disposed of. Not all prescribed creams were dated when opened, and we found a cream in a person’s bedroom that they had not been prescribed. It had no label, and leaders in the home could not tell us who it belonged to. We also found nutritional supplements belonging to 1 person stored in another person’s bedroom. One person’s medicine stated ‘do not give with other medications’ on both the label and the electronic system. Staff were not aware of this instruction, and the medicine was routinely given at the same time as other tablets. This meant the person was not receiving their medicine as prescribed.

These issues showed that medicines were not always stored or monitored safely, increasing the risk of unsafe practice. Senior staff counted medicine stocks daily, and nurses checked the balance of controlled drugs weekly, but wider medicines audits were only carried out twice a year. This meant some of the issues we found had not been identified through routine checks.

We did see some positive practices around medicines. Medicines were administered by senior staff who had received additional training and were checked as being competent to do so. When people needed medicines as required, for example an analgesia or a laxative, this judgement was made by registered nurses in the home, who also administered more complex medicines such as insulin and controlled drugs. Medication records were held electronically, and the system gave staff clear instructions when medicines were due. Time specific medicines were given on time, and all people told us they received their medicines when they needed them.

When people needed to take their medications covertly, there was clear information on how this decision had been reached, who had been involved in making the decision and instructions on how the administration should happen.