Prema Court

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 requires improvement. We identified a breach of regulation in relation to governance systems, leaders and managers had not provided effective oversight helping to identify and embed areas for improvement.At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of the legal regulation in relation to governance systems.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Actions required following our last assessment remained outstanding. Whilst a service improvement plan was in place this had not been effectively implemented to ensure required improvement action had been taken. There had been a lack of consistent leadership and direction. On-going concerns remained in relation to the premises and the care and support people received.

Staff were seen to interact well with people throughout our visit. However, there was little meaningful, structured activities taking place providing people with opportunities both in and away from the home.

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 was a failure by the provider to acknowledge the poor quality of the service. The provider was not proactively recruiting inclusive leaders. Stable management arrangements have not been in place since the registered managers departure in July 2024. Since then, 3 further appointment were made however unsuccessful. A new manager has now been appointed. Application to register with CQC is to be made. There was a culture of apportioning blame on previous managers for the failure to improve the home and both the compliance manager and the operations support manager told us the previous manager had failed to implement effective systems. This had not provided stable and effective management of the service to help drive improvement and improve outcomes for people living at the home.

The current manager had been employed at the home as a deputy manager, 3 months prior to our assessment and then promoted as manager in January 2025. The manager said they were being supported by the operations manager and were keen to develop in their role. However, they recognised their own areas of development in relation to the type of service provided at Prema Court. Staff spoken with said they felt they could approach the new manager and new deputy manager if needed.

Our assessment of management systems again showed further work was needed to support the manager in their role and ensure robust systems providing clear oversight of the service were effectively used.

People did not always feel they could speak up and that their voice would be heard.

Staff told us they could speak with the new manager. However, felt this was not always consistent and their views were not always taken into consideration across the management team. One staff member said, “Responses vary depending on leadership, there is room for improvement in implementing staff suggestions more effectively”. Staff also said consideration needed to be given to safe staffing levels to support both people living at Prema Court and staff.

Staff confirmed procedures for raising concerns were in place including a whistleblowing procedure.

The provider had offered training for staff in equality and diversity. However, there was a lack of evidence to show the provider had actively reviewed and improved organisational culture.’

Opportunities for meaningful engagement with staff, such as individual supervisions, were not embedded enabling staff to share their views and ideas about the service.

The staff team which comprised of both male and female staff, said the new manager was approachable. However, feedback was mixed about the support provided, particularly in relation to staffing levels. We were told during one shift, staff had been allocated to work alone with 11 people. During this shift they were assaulted by someone at the service resulting in hospital treatment due to injuries sustained.

The service had an equality and diversity policy, which outlined the aims of the service in relation to respecting and valuing difference, and promoting equality, diversity, and human rights. However, care and support were not planned and delivered in a way which met people’s individual wishes and preferences, promoting and enabling people to take part in meaningful opportunities in a safe way.

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.

Following our last assessment, we identified governance systems needed to be improved. We wrote to the provider requiring them to provide a monthly report on the action and improvements being made. Information was provided; however, we found during this assessment the improvements shared with us in these monthly reports, had not been made, sustained and in some cases completed and the breaches identified at our last assessment had not been met.

A review of records showed audits and checks had been carried out in areas such as health and safety, infection control, safeguarding and catering. However, these were not sufficiently robust to help identify the issues found during this assessment nor was there evidence where actions had been identified these had been acted upon in a timely manner.

We were advised a more robust quality assurance system was being introduced in April 2025. These were to be completed by the manager on a weekly and monthly basis and reviewed by senior managers. This area was identified as a regulatory breach at out last assessment in May 2024. This did not demonstrate effective and timely action had been taken to make and sustain improvement required across the service, to ensure people’s needs were met and positive outcomes achieved.

Accidents and incidents were not effectively reviewed to identify themes and action taken to minimise potential risks or behaviours. Policies and procedures were not reviewed or updated and not followed in practice. We noted training had been completed in duty of candour reinforcing the providers responsibilities of being open and honest when something goes wrong with peoples care, causing or potentially causing harm or distress.However, a review of records showed the provider had failed to ensure events potentially impacting on the safety and well-being of people had been reported to the commission as required by law.

The provider had improved working relationships with partner agencies. On-going improvements and learning were still needed as identified by other stakeholders. The local authority and commissioners continue to carry out regular monitoring visits to review areas of improvement required by the provider.

Staff told us there was good support from the local GP surgery, with weekly visits made to the home. With the service no longer providing nursing care alternative arrangements had been made for people to attend regular clinic appointments to receive their planned treatment.

On-going fire safety measures remained outstanding. During this assessment a further inspection was undertaken by the fire service. This identified further work required to ensure safety systems were in place in the event of an emergency.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Effective systems were not in place to help identify areas of learning and drive improvements. The lack of consistent management had impacted on the ability to make and sustain improvements. A new manager appointment had been made. The new manager acknowledged they too had additional learning needs to enable them to support both people at Prema Care and the staff team.

Areas of improvement identified following our last assessment in May 2024 had not been made. At that time, we were told quotes had been obtained for some areas of work to improve the environment and fire safety. However, during this assessment, we found work remained outstanding.

The provider has recently made changes to their registration. This meant nursing staff were no longer working at the home. Alternative arrangements to ensure the continued monitoring of people’s health and well-being had not been considered and planned for to ensure continuity of peoples nursing care.

A service improvement plan had been put in place by the local authority. Visits continue to be made to address the shortfalls they found and support ongoing learning and improvements.