Nightingale Court

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 requires improvement. At this assessment the rating has changed to 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 the legal regulation in relation to governance at the service.

This service scored 36 (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 demonstrate a shared vision or strategy which promoted transparency, equity, equality, human rights, diversity, inclusion, or meaningful engagement. There was no clear leadership culture embedded within the service, and no evidence that the provider had a strategic understanding of the challenges faced by the service or the needs of the people it supports.

Some people’s relatives told us opportunities were not always provided to give feedback, and not all concerns were recorded and acted upon by the management team.

There was a lack of shared direction and cohesive culture within the service. There was little evidence of effective leadership guiding day-to-day practice. This absence of a clear, shared vision contributed to inconsistent standards of care, and a lack of accountability.

The provider did not have a clear structure of 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.

Leaders did not have the skills, knowledge, experience and credibility to lead effectively. The service had not sustained any significant improvement, and people did not receive safe care and treatment.

The registered manager told us they carried out daily walkarounds, but these had failed to identify what we found on inspection. The management team had also failed to identify and act where care and support could be improved, or practice challenged.

Leaders were not always alert to examples of poor culture within the service, which had a detrimental impact on people. Leaders had failed to identify and act on the widespread risks highlighted within this inspection. Leaders did not always lead by example; there was a strong emphasis on promoting closed culture and not taking people’s concerns seriously.

Following our inspection feedback the registered manager resigned from the post and new acting manager was introduced to the service.

Staff meetings were regular, and staff were positive they could approach the registered manager or the provider with concerns.

However, we received mixed feedback from relatives in relation to being able to raise concerns or complaints. One person’s relative told us, “I’ve been to the office to speak to [registered manager], but they are not a nice person. I had complaints because (relative) was left in their room long time, they had no drink, no dinner and on that day, I knew something wrong was with (relative).” We found no evidence of the complaint from the relative being recorded. Another person’s relative told us they were not treated well after raising complaint with the management of the service. The relative told us, “The manager told me: "You - in my office!" That woman makes me sick!”

The provider valued diversity in their workforce. There was an open and inclusive recruitment procedure, and the staff team consisted of people from various backgrounds and cultures. Some members of staff had worked at the home for many years. It was evident staff felt valued, and there was a shared commitment to continuous improvement. However, this commitment was not always shared by the leadership of the service.

Staff were recruited safely, and the provider supported staff with flexible working arrangements and reasonable adjustments to accommodate personal circumstances and promote wellbeing. All staff had completed training in equality, diversity, and human rights.

The provider continued to fail to ensure there was effective oversight to assess, monitor, and improve the quality and safety of the service. Systems and processes had failed to identify and mitigate risks. This has put people at continued risk of not having their needs met.

The registered manager and provider had not identified care plans and risk assessments lacked important information or were inconsistent. Systems to monitor the service were not effective, for example the issues we found with medicines had not been identified through the audits which had been completed.

Systems and processes in place to gain people’s consent and make decisions were ineffective and did not demonstrate care was always provided in line with legal frameworks.

Systems and processes were not in place to support the mitigation of risks to people or continued improvements. For example, one resident only had 3 accident/incident forms related to falls for the last year, however, according to the person’s daily logs they had 4 falls between 1st July - 31 August. None of them were recorded on the accident/incident form. There was no detail to demonstrate what had been done in response to the incidents to mitigate the risks to the person, there were only daily logs confirming the falls.

During our assessment we found the management team failed to notify CQC of significant events, such as injuries, falls and safeguarding incidents. These are required to allow CQC to complete their regulatory duties and ensure ongoing safe and effective care is provided. Therefore, the provider was not working in accordance with CQC regulations.

The provider did not understand their duty to collaborate and work in partnership to make services work seamlessly for people. There was a lack of understanding around their responsibilities in managing and supporting people’s health needs.

People and their relatives told us they were confident the service would contact healthcare professionals when required. However, during our inspection we found some care plans lacked details instructing staff when to contact healthcare professionals.

Some healthcare professional noted a lack of effective information sharing of people’s health needs between staff. For example, a member of care staff had recorded in one person’s care logs a concern, but this information had not been passed on to senior staff to action. This could lead to delays in gaining timely intervention for people of health conditions which could then further deteriorate.

Leaders lacked a clear understanding of how to implement effective improvements. Existing systems for monitoring the service were inadequate and not used effectively to support progress. There was no learning from when people were put at risk and exposed to harm.

Actions were not consistently recorded where issues had been identified. For example, audits identified broken radiator covers as an issue in May 2025 and then this issue was mentioned in the provider’s health and safety audits every week until our visit. There was no action plan in place to resolve this issue, and it remained unaddressed until our visit.

Medicine audits were carried out weekly, however, they had failed to identify the issues we found during our inspection.

There were no processes in place to effectively monitor accidents and incidents, identify any trends or required learning to reduce the risk of reoccurrence. Failure to operate effective governance systems or have effective oversight placed people at increased risk of harm.

Quality assurance systems were either not in place, inconsistently applied or ineffective, which limited the service's ability to drive improvements which promoted equity, positive outcomes, and enhanced quality of life for people using the service.