Royal 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, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this newly registered service. This key question has been rated 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.

This service scored 61 (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 always have a clear shared vision, strategy and culture that was understood and consistently demonstrated across the service. People and relatives described a friendly, homely service and spoke positively about staff, but the improvement plan had not involved staff or people using the service and meeting records did not show that requested changes had been acted on. The manager had started to strengthen communication, resident and relative engagement, staffing arrangements and expectations, but these developments were recent and were not yet fully embedded. A relative said, “The staff and manager have been brilliant. They have made us feel welcome.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had made improvements to the service and were continuing to drive further changes. The manager was visible within the service, provided operational support when needed, and had taken action to address identified concerns. Feedback about the manager was positive, with one relative telling us, “The new manager is doing very well and making a difference.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt supported by the management team and were able to approach the manager for advice, guidance, and help when needed. One staff member told us, “The manager helps if I reach out. The team are good.”

The manager used team meetings and group supervision sessions to discuss lessons learned, share information, and encourage staff to reflect on their practice. Staff said these opportunities helped them communicate openly and work together to improve outcomes for people.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had taken steps to support staff wellbeing and engagement, including consulting with staff on matters affecting them. Records also showed staff had opportunities to raise concerns and discuss workplace issues.

The provider did not have effective governance systems to ensure clear accountability, monitor performance, identify risks, and drive sustained improvement. Governance shortcomings had contributed to risks remaining unidentified, insufficiently monitored, or unresolved across several areas of the service, including medicines management, care planning, fire safety, water safety, infection prevention and control, and environmental safety.

Although audits and monitoring systems were in place, these did not consistently lead to clear action plans, timely follow-up, or evidence that identified issues had been resolved. For example, maintenance records did not consistently demonstrate action taken in response to identified defects. We also found examples where suggestions and requests raised by people and relatives had been recorded in meeting minutes, but there was not always clear evidence these had been addressed.

The manager had recognised these issues and had begun strengthening governance arrangements by introducing revised audits, evidence logs, and action-tracking systems. They acted in response to feedback provided during the assessment. While these improvements demonstrated a commitment to improving oversight and quality, they had been introduced recently and had not yet been embedded long enough to demonstrate they were operating effectively and delivering sustained improvements over time.

The provider worked with external agencies and relatives to support people and improve the service. Evidence included engagement with the local authority and integrated care board, contact with GPs and pharmacists about medicines, work with social workers during admission, and efforts to strengthen links with families and local schools and nurseries. Relatives said they were kept informed about health changes and could approach staff with questions. A relative said, “They keep us in touch with everything.”

The provider had started to make improvements to the service but did not yet have a consistently effective system for learning from incidents, audits, complaints and feedback. Audits, accident information and meeting feedback did not consistently show completed action, follow-up or evaluation of whether changes had worked.

There was evidence of responsive improvement during the assessment, including medicines protocols and retraining, revised cleaning arrangements, environmental action, family activities, reduction in agency use and new ways of gathering meal feedback. These actions were positive, but they were recent and some were completed only after the assessment identified shortfalls, so there was insufficient evidence of sustained continuous learning or innovation across the service.