Nightingale Court

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Good

• Caring

  Requires improvement

• Responsive

  Good

• Well-led

  Inadequate

Our view of the service

Nightingale Court is a care home that can accommodate up to 43 people. The service provides support to older people who may have dementia. At the time of our inspection there were 31 people living at the service some of whom were living with dementia. The inspection was unannounced and was undertaken in response to concerns raised about the service, specifically regarding governance of the service, management of medicines, record keeping and management of accidents and incidents.

During the inspection, we found evidence indicating people were at risk of harm due to these issues. During our inspection we identified 3 breaches of legal regulations related to Need for consent, Safe care and treatment and Good governance.

We carried out unannounced visits on 8, 14 and 23 September 2025. The inspection was carried out by 4 inspectors and 1 medicines inspector. As part of the inspection we reviewed records, spoke with staff, leaders and relatives and reviewed records in relation to people’s support. We looked at a range of quality statements across the domains of safe, caring, and well-led.

The provider failed to ensure appropriate systems were in place to manage medicines safely. Audits were being completed; however, they failed to identify the issues and concerns found during the inspection.

Management had failed to recognise where safeguarding incidents had occurred and as a result had not reported these appropriately to the relevant authorities. In addition, where accidents and incidents occurred and action was taken at the time, learning from these was not embedded robustly to help reduce future incidents.

People did not always have appropriate care plans to guide safe practice. Some records related to people’s care were missing or had significant gaps.

People were not always safeguarded from abuse, and we found there was a lack of documentation in place to support consent. The provider failed to use effective systems to ensure the service was working within the principles of The Mental Capacity Act 2005.

We found there was a closed culture within the service

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.

We have asked the provider for an action plan in response to some of the concerns found at this inspection.

People's experience of this service

Not everyone at the service was able to speak with us. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. Although we observed multiple positive interactions between staff and people, we noticed people were not always offered choices and we reported our concerns due to poor moving and handling techniques used by staff.

During our inspection we interviewed 6 people’s relatives. We received mixed feedback regarding care and support provided to people. While some relatives were happy about the care and the governance of the service, other people’s relatives raised their concerns around the management of accidents and incidents, unexplained bruising and the management not always informing them about outcomes of safeguarding concerns.