Palm Court 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 Requires Improvement. At this assessment the rating has changed to Inadequate: 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 legal regulation in relation to governance and oversight.
 

This service scored 29 (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. There were widespread failures across the service and the culture of the service did not promote people’s safety or increase their experience of good care.

Staff and leaders did not demonstrate a positive, compassionate, listening culture that promotes trust and understanding between them and people using the service and is focused on learning and improvement. Staffing levels had not been maintained to meet the needs of people living in the home, high staff turnover and the use of agency staff had caused further instability in the home. Staff told us they worked hard to improve the service but did not feel adequately supported to sustain these improvements.

Leaders did not ensure there was a shared vision and strategy and that staff in all areas knew, understand and supported the vision, values and strategic goals and how their role helps in achieving them. The provider had not made significant improvements since the last inspection, documentation was not in place to inform staff about people’s care and nursing needs. This meant that new and agency staff did not have the relevant information about people to be able to deliver care to meet people’s needs.

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.

The home had not had a registered manager in place for over a year. The acting manager had commenced the process of registering with the Care Quality Commission.
Although staff had been employed in designated roles, staff were not able to carry out these roles effectively as they were required to pick up a number of other tasks which impacted on their time to complete the things they were employed to do. We observed staff not employed to provide care having to assist people with their meals at lunchtime as no care staff were available. Training and competencies were out of date, supervisions had not been completed, new staff had not received inductions and clinical staff did not have the time to update documentation as they had been supporting care and nursing staff with other tasks.

We found that a number of management tasks had been delegated to other staff, some staff lacked experience to carry out these tasks effectively and there was no provider oversight to ensure things were being identified and actioned appropriately. Staff did not feel the provider was open and they did not feel involved in decisions or that their views and feedback was valued. Staff told us all decisions had to go through the provider even the ordering of small equipment. This impacted on people’s safety and demonstrated a lack of oversight and support in place for staff. The acting manager did not have access to a number of areas of documentation which were needed to provide assurances and ensure the safe running of the service. They were not involved in all decisions regarding the day to day running of the home. Therefore, they lacked oversight of all areas required as a manager.

Staff told us they were often reluctant to speak up as they felt their voice would not be heard. When staff had raised questions or concerns, for example at staff meetings, these had not been responded to and no actions were documented to show the provider’s response.

Staff told us they were told about changes after they had happened, but that these were not discussed with them, therefore staff did not feel their views were valued and they did not feel supported by the provider.Staff told us they were thinking of leaving if things did not improve, all staff we spoke to felt that staffing levels needed to be increased to meet people’s complex needs. The acting manager told us they felt more staff were needed. There was an emphasis on staff numbers being based on the number of people living at the home, rather than being assessed against the level of people’s individual complex care and nursing needs.The provider told us they had recently employed some new and returning staff. One staff member told us, “I have told the provider I will only stay if things get better.” Another said, “It's too much just me all the time. We are doing our best, but we are too stretched, you can’t get anything done.”

The training and quality assurance lead took on the role of Speak up Guardian’ in October 2024. They told us they were keen to improve communication and to help staff feel they can speak out, to make a more positive culture in the home. Staff told us they felt they could speak openly to the speak up guardian. However, staff felt their views were not valued by the provider.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse workforce. Some staff had been working at the home on sponsorship from abroad. However, the provider had not ensured a consistent approach to ensure the continuous management and oversight of all staff, to make sure that all staff member’s specific support needs were identified and any further training or support provided.

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.
There have been multiple previous breaches of regulation. The rating of this home has been inadequate or requires improvement over a number of previous inspections. Although initial improvements had been implemented by the provider following previous inspections, these had not been sustained and the provider is still in breach of regulation at this inspection.

There was a lack of effective provider oversight. Audits, reviews and governance had not been maintained. Auditing was either not completed or was not robust and as such had not identified the numerous concerns we found during this inspection. Tasks had been delegated with no provider oversight.

The provider did not have effective systems and processes in place to continuously assess and monitor the quality and safety of the home. They had not assessed and monitored risks relating to people’s health, safety and welfare. Documentation was not accurate or complete and did not reflect people’s needs. Processes to monitor and review accidents, incidents and unexplained bruising were not in place. This meant people were at risk. Accidents and incidents were still showing as awaiting review and sign off, dated back to August 2024, with no monthly oversight or analysis completed to identify any trends, themes or learning.

An external consultant had been employed. They had completed a review of areas of the home and identified a number of the concerns we found at this inspection. The results of this review had been discussed in a staff meeting on 11 March 2025. However, prompt action had not been taken to improve.

The provider had not taken urgent steps to rectify critical actions identified in a fire risk assessment completed by an external specialist in January 2025. We also found a number of other fire safety issues which had not been addressed by the provider in an acceptable timescale to ensure robust fire safety systems and processes were in place.

Following this inspection the provider sent us an improvement plan. However, many of the improvements had been identified at previous inspections and included in action plans sent to us by the provider. These systems, processes and provider oversight were not in place or embedded into practice. We found improvements had not been sustained. Robust systems had not been put in place to ensure the continuous and sustained improvement required.

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

Care plans and risk assessments did not reflect people’s current needs. Therefore, it is unclear how accurate information was being shared with other health professionals involved in people’s care. We saw people had hospital passports, staff told us these were to assist with admission to hospital. However, these had not been reviewed and included incorrect information. For example, one person’s nutritional guidance had changed and the hospital passport had not been updated. Feedback from health specialists had not been added to people’s care documentation to ensure people received safe and consistent care. New and agency staff told us they had not read people’s care documentation.
 

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.

There was a lack of provider oversight. Systems and processes to ensure the safe and effective running of the home were not in place or being followed. We found multiple examples where lessons were not learned by the provider because they did not have the information they needed to identify the trends and themes that would make this possible. There were ineffective processes to ensure that learning happened when things went wrong, and from examples of good practice. Leaders did not encourage reflection or collective problem-solving.

Staff and leaders did not have a good understanding of how to make improvement happen. Their approach was not consistent and did not include measuring outcomes and impact. Staff and leaders did not ensure that people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives.

We found repeated breaches of regulations at this inspection. The provider had not implemented and sustained improvements or demonstrated learning taken forward following previous inspections.