Royal Leamington Spa Nursing Home

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 good. At this assessment the rating has changed to 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 governance at the service.

This service scored 46 (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.

Care practices were not always reflective of current standards and guidelines. For example, prescribed thickener was not safely secured and risks in the environment were not mitigated. Staff knew doors that should be locked were not, records were not always accurate, and pressure relieving equipment was not always set correctly, despite staff telling us they should be. This showed some unacceptable practice had become ‘normalised’ and the culture meant these things often went unchallenged. Conversations with the registered manager showed a lack of knowledge around accepted practices in the home and a fundamental lack of effective audits and checks, meant there was lack of direction to drive up standards and expectations.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There were no quality assurance checks made by, or on behalf of the provider to ensure internal audits were thorough and effective. The registered manager told us they did not complete internal audits as they ‘were not impartial’ so audits were delegated to other staff. Audits to oversee safety were scheduled throughout the year, medication audits were completed every 6 months, and health and safety checks were carried out 3 times a year. These audits had failed to identify and mitigate the risks we found in the service.

Following feedback from our first visit, the registered manager provided an action plan to address the serious concerns we had identified. When we returned on the second day of the inspection, several of these issues were still present, despite the manager’s assurance that they had been resolved. This showed the registered manager did not fully understand the seriousness of the concerns, and that a lack of ownership continued to affect the safety and quality of care people received. Most actions taken involved simply telling or reminding staff of their responsibilities, without any checks to ensure these instructions were being followed in practice.

Throughout the inspection, we raised multiple concerns with the registered manager, including matters relating to fire safety, security and environmental hazards. The registered manager did not demonstrate ownership of these issues and offered limited ideas about how they could be identified, managed or resolved. For example, areas affected by refurbishment work were left unlocked and contained hazards, yet there had been no consideration of how to manage these new or emerging risks. When we raised concerns about an internal gas pipe running through a person’s bedroom and behind combustible materials, the registered manager acknowledged they were aware of the pipe and shared similar concerns. They later arranged for the pipe to be boxed in, but it was unclear why this action had not been taken before our visit. Overall, there was a lack of insight, knowledge and urgency in responding to safety concerns. Leaders were not proactive in developing risk‑management strategies when issues were identified

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People told us they would be confident talking to the registered manager or the deputy manager and felt any concerns they raised would be taken seriously. One person told us they had shared feedback about a member of staff and spoke positively about how the registered manager had used the information to resolve the situation and improve the staff member’s practice.

Staff said the culture in the home was positive and there was a range of leaders they could approach if they had concerns. A member of staff had very recently been appointed as a ‘freedom to speak up guardian’ to support their colleagues to raise any concerns. It was unclear whether this was embedded within the home as no concerns had been shared at the time of our inspection.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed staff from both the local area and from overseas. The team represented a range of backgrounds, cultures and experiences, and this diversity contributed positively to the skills and perspectives within the home.

Staff told us they felt they were treated fairly and had several leaders they could approach for support. They described a workplace where they felt included and able to raise concerns or seek guidance when needed.

The provider also recognised and valued staff contributions. Staff told us they were regularly thanked for their hard work, and the provider showed appreciation by arranging occasional meals or social events away from the home. This helped promote a sense of teamwork and belonging.

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.

Governance systems were not effective because issues we identified during this inspection had not been identified by the provider’s own governance system. Where the provider was confident of improvements through some of their checks, for example in medicine management and environmental risks, we found improvements were still needed. Where quality checks when delegated to others, the registered manager was not always aware of what was and what was not checked as part of those processes. There was no managerial oversight to ensure delegated audits had accurately reflected areas for improvement or driven improved practice. For example, improvements to fire safety were still required.

We were not assured that the provider could make and sustain the required improvements at the service. Information gathered through checks and audits was not being used effectively to monitor quality or drive change. The registered manager did not fully recognise the seriousness of the concerns we identified, and actions taken were reactive rather than proactive.

These issues showed that governance systems were not robust, and the provider did not have effective arrangements in place to ensure safe, consistent and sustainable care. The service had not sustained their compliance since the last inspection, resulting in breaches of the regulations being identified.

The provider did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not consistently share information and learning with partners or collaborate for improvement.

People and relatives were not always informed of changes made in response to identified risks, including those relating to safety within the environment. Relatives approached us during the inspection to ask why fire doors were required to remain closed, as they had not been made aware of the reasons by the provider. This meant people and their relatives did not understand the purpose of key fire safety measures and were not able to support them in practice. This lack of communication meant they could not support safe care and created confusion and distress. Alongside the need for external agencies to intervene, this demonstrated a failure to work in partnership with others to identify, manage and respond to risks.

The provider did engage with external partners, including colleagues from the Integrated Care Board (ICB). However, communication was not always clear, consistent or reliable. For example, information relating to the number of staff required to safely evacuate people in the event of a fire was not clearly established, and messaging from the registered manager changed. This created confusion about how risks were being managed and whether appropriate arrangements were in place to ensure people’s safety. This demonstrated a lack of clear leadership, oversight and coordination with partner agencies regarding critical safety information and meant the provider could not demonstrate a consistent or reliable approach to managing risks.

We saw evidence people received support from external health services. These included the local GP, speech and language therapy and dieticians. Students from local colleges and universities were invited to gain work based experience in the home and nursing staff had gained additional qualifications to support and assess those students pursuing a career in nursing. Close links had been developed with local partners such as schools, places of worship and charity organisations. An activity dance group had offered dance opportunities to people, both in and out of the home. Families, and important links with friends and local communities were supported, however, better communication was needed

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe, effective practice and research.

The provider had previously been subject to fire safety enforcement, which required them to review and strengthen their fire risk assessment processes. However, at this inspection we found that fire risk assessments had not been updated during building works and significant risks remained. These risks were not identified through the provider’s own systems and required external intervention, including enforcement action by the fire service. This demonstrated that governance systems were not effective in embedding learning or sustaining improvement, and that risks to people’s safety continued to go unrecognised and unmanaged.

When issues were identified within the home, these were shared with the staff who were on shift during stand‑up meetings. This approach meant the provider could not be assured that staff who were not on duty had received the information or understood the required actions. Wider staff meetings were not held regularly, limiting opportunities for shared learning, reflection, and consistent communication across the whole team.

Some people had been invited to participate is a research study, trialling how virtual reality could improve physical activity. The provider purchased a VR headset, and this had been included in weekly activity provision.

Both the registered manager and the provider told us they were committed to making the necessary improvements. However, their approach to learning was largely reactive. They tended to wait for external professionals to point out risks or required actions, rather than proactively identifying learning opportunities themselves. This limited the service’s ability to drive continuous improvement and reduce avoidable risks.