Nightingale Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, particularly in relation to accidents and incidents and medicines. They were also in breach of regulations in relation to staffing levels and need for consent.

This service scored 34 (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 listen to and record complaints and did not always investigate or record accidents and incidents. Lessons were not learnt to continually identify and embed good practice.

There was not always due consideration when mitigating risks of closed cultures. Some people’s relatives told us their complaints were not being recorded or investigated. We reviewed the log of complaints and found no complaints had been recorded between January and August 2025 regardless of Care Quality Commission being aware of complaints that had been raised with the management of by relatives.

Incidents and accidents were not always recorded and investigated appropriately. One person’s relative informed us not all incidents of falls were being recorded and the falls risk assessment did not reflect the person’s needs. We requested a log of accidents and incidents related to falls of this person. We found not all falls have been identified for the person and recorded as accidents and incidents. The person’s falls risk assessment stated ‘no history of falling’ regardless of multiple falls being recorded by the service. As the information from accidents and incidents was not always captured and analysed, we found actions from this were not completed and lessons were not learnt to prevent reoccurrence of accidents and incidents.

The provider did not always work well with people and health system partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. Health risks to people were not always well managed, and care plans did not always reflect people’s needs. Care plans did not contain current, up to date information, for example, one person had respiratory needs, however, there was no related care plan and the person’s condition was not mentioned in any sections of their care plan. There was conflicting information regarding people’s allergies and medicines used. For example, one person’s front page on their Medicines Administration Records (MAR) mentioned multiple allergies, however, every other page in the person’s MARs mentioned ‘no allergies’. Another person had a medicine mentioned in their care plan to be administered for their specific health condition. However, the medicine was never prescribed to the person, and the type of medicine was not used to treat the specific health condition. This meant if people were seen to by other services, they would not have the most current information to meet people’s needs and keep them safe.

People were not always protected from the risk of abuse. Most of people’s relatives told us they felt people were safe in the service. Staff understood their responsibilities in relation to safeguarding and knew how and who to report any concerns to. However, during our inspection we were provided with photographs by relatives of some people’s unexplained bruising. We found staff meeting minutes from February 2025 in which staff were told not to investigate safeguarding incidents and not to take any allegations made by residents seriously. The meeting minutes stated, “We are not CID we are not investigators and residents have dementia.” We were therefore not assured that all people were safeguarded.

People’s health needs were not well documented, and staff were not always provided with appropriate guidance on how to act upon some risks. For example, one person had an epilepsy care plan in place. The person’s care plan failed to mention type of seizures, auras, how to recognise any changes, or what emergency treatment may be needed, when was last seizure or how often they occurred. It also provided incorrect information about their epilepsy medicine. Although it was recognised by the provider staff need to completed epilepsy training, and this was planned on the day of the inspection there was no single member of staff trained in epilepsy awareness.

Some people had catheter care plans and risk assessments. However, these lacked details such as how to secure the leg bag to the leg, how to position the catheter to ensure drainage, when to empty the bag, how to clean drainage port and how to recognise signs of urinary tract infection and signs of sepsis.

On the second day of our inspection, we saw multiple radiator covers around the annex area were damaged which could pose a risk to people using the service. We brought this to the attention of the registered manager who told us they were going to start repairs soon. We saw radiator covers were repaired on the third day of our inspection.

Equipment checks were carried out regularly and where one hoist was deemed unsafe, this was replaced by the provider. Gas safety and fire checks were completed and electrical items tested for their safety and compliance.

People were provided with equipment to support them to move around the building safely, such as a Zimmer frame, and where people stayed in their room, they were provided with a call bell or a personal alarm.

The provider did not consistently ensure there were enough qualified, skilled, and experienced staff to meet the needs of people using the service. During the first day of our inspection we observed there were only 3 members of staff at night including the senior member of staff. When the senior member of staff was administering medicines, this left 2 members of staff to assist 19 people with personal care and with assisting people to their beds. All staff interviewed during our inspection mentioned low staffing levels. We saw staffing levels increased on the second and third day of our inspection.

On the second day of the inspection, we spoke to an agency staff member and asked about their knowledge of people’s care plans and risk assessments. The agency staff member was unable to answer. When we raised this with the registered manager, they told us they expected agency staff to work from day one and to read care plans and risk assessments in their free time. The registered manager stated the risk was mitigated by pairing agency staff with regular staff member. The agency staff had no access to the electronic care planning system and relied on regular staff to log on the computer available to them. However, this was not always possible due to low staffing levels.

Staff were recruited through a robust process which included them providing evidence of their performance in their previous role, their right to work in the UK and their fitness for the role. Prospective staff underwent and Disclosure and Barring Check (DBS) prior to commencing work to ensure they were suitable to work in this type of setting.

During our second day of our inspection, we saw a urine bottle with urine left on one resident’s bedside table. We reported this to the registered manager, however, the bottle was not removed. We saw the bottle with urine on a bedside table again on third day of our visit.

On third day of our visit, we found clean towels left on the yellow waste bin in a communal bathroom. This posed a risk of infection. We reported this to the management of the service who told us they would remove the towels and wash them to prevent a risk of infection.

Staff wore appropriate personal protective equipment (PPE), including gloves and aprons, which helped prevent the risk of cross-contamination. The service was clean and tidy throughout. Housekeeping staff were aware of their responsibilities in relation to the prevention of the spread of infection.

Medicines were not always managed safely. During our visit we found that medicines administered when required (PRN) were not always administered appropriately. For example, one person’s PRN was administered continuously for 12 days. One of the side effects of the PRN medicine was muscle weakness. The person suffered 2 falls within 3 days, with ambulance’s being called, however, staff continued to administer PRN medicine without seeking medical advice. There were no updates in the body of the care plan which stated the resident had 2 falls in 3 days. There was an update on the risk assessment records. The regular administration of the PRN medicine was not reviewed by the GP as the GP was not informed the resident was given the medicine on a daily basis. When this regular administration of PRN medicine was identified by night staff, no incident was logged by the service to provide learning to staff.

PRN medicines should not be time restricted on medicines administration record (MAR) charts for resident use there was evidence of MAR charts having timings for PRN medicines on the inspection. This meant there could be a delay in people being given medicines such as pain relief when needed.

We found covert medicines were not always administered safely. For example, one person’s medicine had been administered covertly since February 2025. However, the person’s mental capacity assessment regarding medicines administered covertly was completed on 31 July 2025. There was no evidence of any next of kin being involved in the mental capacity assessment as we were told the name had not been documented. The person’s MAR chart did not state they were on covert medicine. There was no pharmaceutical advice on how to administer the person’s medicine safely covertly.

Another person was administered covert medicines. There was no pharmaceutical advice on how to administer medicine safely covertly. Staff told us the person was given their medicines in porridge or yoghurt. However, the person’s medicine stated on the MAR ‘do not crush or chew’, so adding to food to chew would was not appropriate. The person’s MAR also stated the person could have their medicines covertly.

Controlled medicines (CD) stock was balanced weekly, which required 2 people’s check as per provider’s policy. However, there was only one signature on all stock checks which had occurred on 22nd September 2025.

There were 2 incidents with people’s CD patches, none of them was reported internally or externally.

We found the medical fridge had been faulty for more than 3 months. A domestic fridge was in place, however, there was no lock and no medical temperature probe to ensure accurate readings were being recorded. Staff were not recording the minimum and maximum of fridge temperature. The fridge in use had ice formed around it which raised concerns it was not being properly maintained. The fridge was storing insulin and could be a risk of medicines quality being compromised. We reported this to the provider who replaced the medical fridge following our visit.

Medication administration competencies staff were signed as competent by the registered manager and the deputy manager. However, when asked the deputy manager, they told us they had no additional training or qualifications to sign off staff as competent.