Kings Court Care 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, People-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service. This key question has been rated 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 staffing, and governance at the service.

This service scored 32 (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 not established a shared vision, strategy and culture based on transparency, inclusion, engagement and meaningful involvement. People, relatives and staff were not consistently involved in decisions affecting the service.
People, relatives and staff told us they had not been consulted before agency workers were accommodated within the home. Records and feedback confirmed residents, relatives and the wider staff team had not been involved in discussions about this arrangement, despite its impact on the home environment and daily life within the service.
People and relatives raised wider concerns that decisions affecting the service were not always made with their involvement. Several people felt organisational decisions were implemented without meaningful consultation and that their views did not consistently influence how the service was run.
Staff feedback reflected similar concerns. Staff described inconsistent leadership approaches and uncertainty regarding expectations and decision-making. One staff member told us, "Each manager comes with different ideas," while another described the service as, "A beautiful home, but there is no staff." Staff told us they did not always feel involved in decisions affecting their work or the development of the service.
Additional staff feedback described a culture where appearance, presentation and organisational image were sometimes perceived to be prioritised above people's experiences and outcomes. Staff told us some decisions appeared to be driven by aesthetic or reputational considerations rather than residents' comfort, wellbeing and individual preferences.
Although many people spoke positively about the care provided by frontline staff, feedback from people, relatives and staff demonstrated the provider had not developed a culture where engagement, consultation and involvement consistently informed decisions affecting the service.
 

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. People and staff spoke positively about the impact of the interim manager and described improvements in communication, responsiveness and presence within the home. Several people told us the interim manager was more approachable and visible than previous managers and had made a positive difference to the service.
However, both people and staff told us the interim manager was responsible for managing two homes simultaneously and was not always available when needed. This affected confidence in leadership oversight and the provider's ability to maintain a consistent management presence within the service. Relatives described occasions when they had struggled to obtain information or speak with a manager, while staff spoke about the challenges of operating without consistent leadership support. Although people and staff recognised improvements under the interim manager, leadership arrangements remained unstable. The provider had not yet demonstrated sufficiently robust and sustainable leadership arrangements to consistently support staff, people and relatives.
 

The provider had not created a culture where people, relatives and staff felt confident to raise concerns openly. Staff feedback identified a reluctance to speak up about issues affecting people using the service. One member of staff told us there was a culture where staff who raised concerns or advocated for residents felt targeted rather than supported. They described an environment where speaking up was discouraged and concerns were not always welcomed or acted upon. Another member of staff told us they did not feel comfortable raising issues and felt unable to challenge poor practice confidently.
People's experiences reflected similar concerns. One resident told us they were worried about raising concerns because they feared negative consequences if they became more dependent or their needs increased. This indicated a lack of confidence that concerns could be raised without adverse impact.
Staff reported feeling that issues raised were not always listened to and that maintaining a positive image was given greater priority than responding to problems when they occurred. Staff also told us senior leaders were significantly more visible during inspection activity than they were in day-to-day operation of the service. This contributed to a perception that concerns were not routinely listened to or addressed outside periods of regulatory scrutiny. These findings did not demonstrate a culture where people, relatives and staff felt safe, empowered and confident to speak up knowing their concerns would be welcomed, acted upon and used to improve the service.
 

The provider did not promote an inclusive and supportive culture where all staff received consistent opportunities for support, engagement and development. Arrangements to ensure staff were treated fairly and supported consistently were not always effective. A significant proportion of care was delivered by agency workers, some of whom had worked at the service continuously for several months. Records reviewed identified examples of agency workers undertaking prolonged working hours, including one worker who completed in excess of 70 hours in a single week. The provider could not demonstrate effective oversight of working hours, rest periods or the potential impact on staff wellbeing and performance.
Despite several agency workers forming part of the regular workforce over extended periods, there was limited evidence that they received the same level of structured support, supervision and development available to permanent staff. We found no records of formal supervision, performance review or structured wellbeing discussions for agency workers who had been working at the service for prolonged periods. As a result, people could not be assured all staff were supported consistently and fairly.
The provider was also unable to demonstrate consistent arrangements for staff engagement. Staff supervision records and staff meetings were irregular, limiting opportunities for staff to contribute to service development, discuss concerns and receive support.
Despite these concerns, staff spoke positively about their colleagues and demonstrated a strong commitment to people using the service. However, workforce pressures, inconsistent engagement arrangements and limited oversight of staff support and wellbeing had negatively affected morale and reduced assurance that all staff were receiving equitable support.
 

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 provider had access to information which identified concerns about people's experiences and service performance but did not consistently act on this information. Call bell monitoring data identified persistent delays in responding to people requiring assistance. Despite this, people and relatives continued to report delays in receiving support and there was limited evidence that the provider had implemented effective and sustained action to address the issue.
Quality assurance and audit processes had failed to identify a range of concerns found during the assessment. These included weaknesses in care records, environmental risks, complaints management processes and agency staff oversight. Records reviewed contained inaccuracies, omissions and conflicting information, including entries referring to the wrong person, contradictory care documentation and incident records which did not always clearly evidence how conclusions had been reached. These issues had not been identified or addressed through the provider's own auditing arrangements.
Governance arrangements for agency staff were particularly weak. The provider relied heavily on agency workers but could not demonstrate effective oversight of their compliance. Staff files reviewed contained significant gaps, including missing DBS evidence, barred list checks, employment histories, references, right to work documentation, conduct in previous roles and evidence of competency assurance. Despite these deficiencies, the provider had continued to deploy agency staff within the service. Taken together, these findings demonstrated ineffective governance. Leaders lacked oversight of service performance, workforce compliance, quality assurance processes and people's experiences. Risks were not always identified or acted upon, resulting in missed opportunities to improve care, safety and outcomes for people.

The provider did not always work effectively with partners to ensure information, learning and improvements were consistently shared and embedded. Whilst partnership working arrangements were established, they did not always result in seamless communication and coordinated care for people.
The provider worked with a range of health and social care professionals to support people's care and treatment. Records showed involvement from GPs, district nurses, occupational therapists and speech and language therapists. During the assessment, we observed healthcare professionals working alongside staff and saw evidence of referrals being made when people's needs changed. People generally had access to external healthcare services when needed, and we found positive examples of partnership working supporting healthcare monitoring, specialist input and end-of-life planning.
However, relatives told us communication regarding healthcare appointments, treatment changes and professional involvement was not always shared proactively. Some described having to seek updates themselves and said information was not always communicated consistently following professional visits.
Whilst professional involvement was evident, the provider could not consistently demonstrate how learning, information and recommendations arising from partnership working were shared, embedded and used to drive improvement across the service. As a result, people could not always be assured that partnership working was consistently translated into coordinated care and improved outcomes.
 

The provider did not consistently focus on continuous learning, innovation and improvement across the organisation and local system. Opportunities to use learning, feedback and performance information to drive sustained improvement were sometimes missed.
The provider had systems in place to support learning and improvement, including incident reviews, falls analysis, root cause analysis, action planning and quality assurance processes. However, these arrangements were not consistently effective in ensuring learning was embedded, monitored and translated into sustained improvements in people's experiences and outcomes.
Concerns relating to people's experiences, staffing arrangements, responsiveness and quality assurance processes continued to be identified despite information being available through complaints, incidents, audits and performance monitoring systems. This indicated that learning and improvement activities were not always resulting in lasting change.
People and relatives continued to raise concerns regarding communication, responsiveness and consistency of care, suggesting previous concerns had not always led to sustained improvement. We also identified occasions where known risks and governance concerns had not been effectively addressed through the provider's existing monitoring processes.
Although there were examples of positive practice, including activity provision, healthcare involvement and some evidence of learning following incidents, opportunities to strengthen outcomes, reduce risks and improve people's experiences were not always fully realised.
These findings demonstrated that while systems for learning and improvement existed, they were not consistently effective in delivering sustainable and measurable improvements across the service.