Palm Court 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 Requires Improvement. At this assessment the rating has changed to Inadequate: This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, managing risk and safe environment. The service was also in breach in relation to staffing.
 

This service scored 34 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was limited documentation to evidence how actions were taken forward and lessons learnt to improve the service moving forward. We found multiple examples where risk to people had not been robustly explored. This included environmental risks, for example, fire safety and the safe use of equipment. There was no detailed analysis of falls, accidents or incidents to identify themes and trends to help improve people’s safety. We found accident, incident reports still awaiting sign off by the provider dating back as far as 3 August 2024 which were still showing as ‘in progress’ or ‘pending signoff.’ This demonstrated a lack of robust oversight of accident and incident processes to ensure all required documentation was completed and appropriate actions taken. Documentation had not been reviewed or updated to incorporate changes to people’s care needs or risks identified.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

We found examples where referrals had taken place to other health professionals, however, risks and actions identified had not been updated in people’s care records. For example, one person had a review by Speech and Language Therapy (SALT) a report sent to the home included nutritional guidance which had not been updated in their care plan or associated risk assessments. People who were found to be at risk due to their low weight did not have information in their care plans regarding fortifying meals appropriately.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Appropriate accident and incident processes were not in place. We found bruising and wounds which had not been documented, and there was a lack of robust systems in place to ensure all accidents and incidents were reported appropriately. Staff told us if they had completed training, and if they had concerns they reported this to senior staff or registered nurses, however we found injuries which had not been identified, and as such had not been reported.

Safeguarding concerns and risks to people were not safely managed. There was no overall analysis completed to identify any trends or themes. A number of wounds and bruising did not have appropriate documentation completed, therefore, it was not possible for the provider to have a clear oversight of how people were receiving injuries and what action may be needed to keep people safe.
 

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.

The provider had not ensured actions were taken to mitigate risk. Documentation and reporting of accidents, incidents and falls was poor. Some incidents and accidents had been handwritten onto the handover form or daily notes, but this information had not documented anywhere else. Accident/incident forms had not always been completed. Those which were in place lacked detail and no action had been taken to follow up or explore how these had occurred. Body maps were not always completed accurately. There were a high number of unexplained falls, bruising and wounds including when people were receiving one to one support.

During the inspection we found bruising and wound dressings on people, staff were not aware of how or when they had occurred, and no documentation was found regarding these. One person had unexplained bruising to the top of their arms. This person received one to one support at night when we were told the injuries had occurred. An inaccurate body map had been completed, there was no documentation completed to provide an explanation regarding how the bruising had occurred and no actions or follow up had been completed. Another person had a dressing on their hand, no documentation could be found relating to this, care staff and registered nurses (RN’s) did not know why the dressing was in place.

Concerns were identified regarding people’s personal safety not being managed. Risk assessments were not updated when changes to people’s care needs had occurred. People at high risk of falls and who required sensor mats to alert staff should they fall in their rooms, did not all have working sensor mats in place. We found sensor mats which required new batteries. One person who was very high risk of falls had what staff told us was a sensor mat at the side of their bed, however this did not have a sensor underneath it, so would not alert staff should the person fall out of bed. Not all RN’s and care staff were aware a sensor mat should be in place for this person. This meant they were at risk. We also saw that sensor mat alarms that did work, were not responded to promptly by staff.

People’s nutritional risks were not clearly documented. One person had a choking risk which had not been updated on their care plan and we found SALT guidance had not been included in a person’s care plan. RN’s we spoke to were unaware this guidance had been received by the home. Staff told us, “Incidents happen and there are not enough staff to deal with them and things get missed” and, “People have complex needs and there are not enough staff.”
 

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 serious fire safety issues which we shared with East Sussex Fire and Rescue Service. These included faults to the fire alarm panel, which had not been addressed in a timely manner. We requested immediate actions to ensure people’s safety. These issues had been identified as critical actions in the Fire Risk Assessment completed by an external company in January 2025. These issues had not been addressed in a timescale which reflected the seriousness of the concerns. We requested immediate actions and interim measures were put in place to mitigate risk until the faults to the fire panel were rectified. We have received confirmation this has been completed.

We also found fire safety concerns in relation to ineffective fire drills, Personal Emergency Evacuation Plans (PEEPS) for people and the maintenance of fire safety equipment around the home, including extinguishers, fire doors and fire exits. A number of new and agency staff were working at the home and the provider had not ensured staff were trained and competent to respond immediately in the event of a fire or emergency evacuation being required.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing levels were not appropriate to ensure people’s safety was maintained and people’s needs could be met. A high number of people required assistance, support or prompting with their meals. At lunch time we saw a staff member who was meant to be providing one to one support for a person, assisted another person with their lunch. This meant the person designated for one-to-one support was not having this provided. People had to wait for long periods before being assisted with their meals, with some people being left to sleep until staff were able to assist them with their meal. We saw people sat in the communal lounge area for long periods of time with limited staff interaction.

For people who were independently mobile, but required support, we saw that even those who had designated one to one staff, often required more than one member of staff to assist them. For example, one person was seen to become distressed, 2 RN’s and a member of care staff were required to support them whilst they walked around the building as they had caused themselves a minor injury and needed treatment. This meant that staff were taken away from the communal area.
All staff were seen to be extremely busy and rushing from task to task to try and meet everyone’s needs. The home used a dependency tool to determine the level of people’s care and nursing needs. However, information recorded in care plans and risk assessments was not up to date and a number of people had fluctuating needs. We spoke to RN’s and care staff who confirmed that staffing numbers were not appropriate as people had complex needs and many required more than one person to assist them, for example, when moving or when they were distressed.

Staff training needed to be further improved. The training matrix demonstrated that a number of staff had not completed all required training. Staff competencies were not being completed in a timely manner, we saw some staff had due dates for May 2025 which had not been completed. There was no evidence a safe and effective skill mix was considered during shifts to ensure there were competent staff on duty to support new and agency staff. We saw that registered nurses had worked over their designated hours to support other staff. Staff with designated roles, did not have the time to complete these roles effectively as they were required to assist care staff, or deal with other tasks around the home. The acting manager had been required to work nursing shifts at short notice when adequate staffing levels were not in place. Newly qualified nursing staff did not have adequate supervision and support in place. New staff had not received a full induction and staff did not receive regular supervision. Agency staff did not know people’s needs and told us they had not read care plans.

Full and complete recruitment records were not available and the acting manager did not have access to some of this information. They were not aware if all appropriate checks and training had been completed by the provider before people began working at the home. Staff turnover had been high. We were told by the provider that recruitment was ongoing, and some previous staff were returning to employment, which would reduce the need for high agency use.

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.

Housekeeping staff were employed. People’s rooms and communal areas appeared to be clean. We saw that red bags were used to carry soiled linens and clothing. However, we observed laundry staff opened these bags before putting washing in the machine. This posed an infection risk. We discussed this during the inspection and were told staff had been reminded of the correct procedure.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicine processes were not always safely followed. We saw staff trained to administer medicines did not follow safe practice. One RN was seen dispensing medicines from the medicine’s trolley in the communal lounge. They left the lounge holding the medicine in a pot and walked to the person’s room. It was not clear why they did not take the trolley to the person’s room before dispensing the medicines. For people who may require ‘as required medicines’ (PRN) this meant staff would have to return to the trolley in the lounge and administer these separately if the person wished to have them. For example, pain relief medicines, which a person may request if they are in pain.
PRN protocols were in place, however, these contained limited information and were quite generic. We were told that PRN protocols were in the process of being updated and would be rewritten by RN’s.

We found equipment in the medicine’s room had not been checked regularly. This included a suction machine which may be required in an emergency. First aid boxes stored around the building had not been checked regularly and some needed refilling. This included the kitchen where catering kitchen first aid kit is required. We spoke to RN’s and care staff and no one was aware who was responsible for these.