Palace House Care Home with Nursing

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 good governance.

This service scored 50 (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 had a shared vision, strategy and culture.The feedback about the management team and the support they provided was very mixed. Staff told us, “The [providers] and the (registered) manager are approachable you are able to go to them with any concerns, and they would sort it” and, “I thought [nominated individual] was unapproachable but not now. I have their direct number [nominated individual] is so supportive he is in the home, and he listens.” However, others told us, “(We are not supported), Staff feel blamed for everything” and, “Staff who speak up are shouted at, ignored, or intimidated. Concerns are not welcomed.”

The management team discussed the actions they had taken to make improvements in the service. They told us they were working hard to engage with the staff team and had recently undertaken an anonymous staff survey to seek the views of their staff.

The provider had developed and were working on an action plan to drive improvements. There was some information on display in the entrance to the service however, most of these related to external guidance. We could see no information about the service, celebrating success or staff updates. A range of policies were in place to support staff in the delivery of care to people.

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

Staff feedback about the registered manager was mixed and some staff fedback that there was a blame culture in the service. They told us, “I have been here for years, it is a lot better now.” However, others said “The culture is fear-based, not open or supportive. Staff are discouraged from speaking up” and, “The service is poorly managed, lacks transparency.” We observed some evidence of a blame culture with the staff team in the service by the management team in relation to some of the concerns we had identified at this assessment. We discussed a number of concerns that we had identified with the registered manager who did not always demonstrate their understanding of the delivery of care and support for people.The provider was visible in the service and following our site visits 2 new managers were present in the service.

There was a range of up-to-date policies and guidance. These had been developed by a specialist company and included links to national guidance and information. The management team told us staff had access to these as needed. There was evidence of management meetings being undertaken. Records included the dates of these, and the topics discussed including areas to support drives for improvement.

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

There was evidence of supervision records being completed but these had not been done for all staff. Some staff told us they had received supervision but not all. They told us, “I may have had 1 or 2 supervisions in the last 12 months” and, “Last supervision was in December these are done regularly the next one is planned soon.” Others said, “Never had one. No one seems to care” and, “Staff do not attend supervision or appraisals. The (registered) manager completes these forms alone in their office.”

The provider told us supervision had been completed recently for all of the staff. However, the record did not include all of the staff team and the individual staff records of these supervision was not provided. Staff files we reviewed did not have signed supervision agreements in them. The provider had developed an action plan which included information about providing supervision to the staff team to support them. The registered manager told us they were improving the supervision record to support and engage with staff.

Not all staff told us they were aware of the whistleblowing policy and felt able to speak up or that their concerns would be listened to. They said, “Freedom to speak up is about being able to raise concerns”, “ Only (heard of freedom to speak up) as a slogan on a poster. You are not listened to” and, “Staff are aware of the term, but it is not supported in practice.The provider told us systems were in place to support staff, including anonymous feedback posters which directed concerns to a central complaints team as well as escalating concerns in the service.

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.

Some, but not all staff that we spoke to told us they felt valued, that the culture at the service was good and the registered manager and provider promoted inclusion and equity in the workplace.

Staffing rotas and the training matrix did not always demonstrate that all staff working in the service had undertaken relevant training to support them in their role.

Policies and guidance were available to ensure staff had access to information to support them. The provider told us a new management structure was commencing in the service, it was confirmed they were in post during the assessment process.

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.

The senior management team were visible in the communal areas during the assessment, we could see they knew people and staff. However, the registered manager did not appear to be visible in the service and where concerns were identified at the assessment the registered manager was not always able to provide evidence to dispute our findings or a rationale for these.

There was a clear lack of governance, oversight and management of the service. It was very difficult to establish who was taking responsibility for governance and oversight and how the management team identified and acted on the findings and concerns. We noted that records we requested took a long time to be provided to us one file was not provided for over 4 hours. Some of the records were very disorganised and the management team were reviewing these prior to our review.

We identified a number of concerns as part of this assessment. These included, the safe management of medicines, safeguarding people from harm, incidents and accidents, the management of risks, infection prevention and control and concerns in relation to the environment. As well as ensuring a sufficient and knowledgeable staff team, ensuring records were detailed and supported people’s needs, the effective management of people’s nutrition and hydration, ensuring people were protected from unlawful restrictions and ensuring people had person centered, individualised care.

There was some evidence of audits and monitoring taking place, but these had not been undertaken on all areas. We noted that all of the audits had been typed with information that was repetitive in their content and did not include information about their findings or identify the concerns we found at this assessment. The weekly audit file only contained 1 copy of a completed audit this was dated 29 December 2025.

There was evidence of senior reviews being undertaken by the provider. These included what areas were being reviewed. There was also some records that confirmed out of hours visits had occurred at the service by the management team. A new check and monitoring system was being developed by the provider. Whilst these will help to support improvements these needed to be more detailed as to what was being reviewed.

The provider had developed an action plan that included information from our findings and the actions they had taken and planned to take going forward, they said they were working closely with local partners and committed to making improvements in the service. They told us they had recruited 2 new managers who would be applying to the Care Quality Commission to be registered, replacing the registered manager. They also told us they had recruited an experienced nurse into the role of clinical lead to support the staff team in their roles and nursing responsibilities.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Relatives confirmed that staff linked in with professionals, where this was required and we saw professionals visiting the service during our assessment. We saw evidence in records that confirmed professionals had been involved but the care records required updating to reflect assessments and guidance.

Staff and the management team told us a range of professionals were involved in people’s care and support, they told us about the complexities of ensuring people received appropriate 1 to 1 support and that reassessments had been requested.

The provider was working with the local health and care partners and meetings were planned to offer support and monitor the service.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The registered manager and senior management team discussed their commitment to make improvements in the service. They talked about the action plan they had developed and continued to commit to take action to make improvements.

Some staff said improvements were noted since we last assessed the service but not all. Some basic information was available and on display, up to date policy and procedures were in place to support the staff team in their roles.

Records about incident and accidents lacked accurate information about the events and the evidence that appropriate actions taken as a result, that would support lessons learned. Statutory notification were mostly being submitted as required to the Care Quality Commission, however some of these were submitted to us at our request as part of the assessment.