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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
Staff reviewed all accidents and incidents that occurred within the home. The new management team delivered training to senior staff, enabling them to review incidents more promptly and take appropriate action when needed.
As part of the accident and incident process, the management team introduced a lessons‑learned system to ensure each event was thoroughly reviewed. Any learning identified was then shared with both internal teams and relevant external partners.
The management team introduced daily meetings to ensure information was shared consistently across all teams, including any lessons learned. Through this improved learning process, the provider adapted the environment to enhance safety for people at high risk of falls. As a result, the number of falls within the home has decreased.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.
At the time of the assessment, the new owner had not yet supported any new admissions into the home. This was due to conditions imposed on the home but, to also give the new management team time to implement and embed new systems into the home. However, robust policies and procedures were already in place outlining how potential admissions would be managed. Senior staff we spoke with were able to clearly describe the process for supporting new referrals.
The home also had strong working relationships with external professionals to support the people currently living in the home. Regular weekly visits from the local GP, advanced nurse practitioners, and district nurses helped ensure that individuals’ health needs were consistently met.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.
Clear safeguarding policies were in place. People were safeguarded from abuse, neglect, and discrimination. People told us they felt “safe” whilst living at the home.
One person told us, “I do feel safe, they (staff) come in to clean my room every day and also always bring me my medication on time”.
A close friend of a person living in the home, who was visiting told us, “I do think that [name] is well-cared for here and safe. I’ve never seen anything that would make me worry they was not ok. If I did, I would speak to one of the staff”.
All staff had received safeguarding training, and staff understood their responsibilities when it came to reporting concerns. All staff we spoke to as part of the assessment were able to tell us what they would do if they had any concerns.
The management team had established a positive working relationship with the local authority safeguarding team. This ensured there was a shared understanding of reporting expectations and allowed both parties to work collaboratively to continue improving the quality and safety of the home.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
The management team had worked with people to implement more robust mental capacity assessment and best interest processes. The Mental Capacity Act 2005 is a legal framework designed to protect and empower people who may lack the ability to make certain decisions for themselves. The new processes put in place involved the person and, where appropriate, their relatives, ensuring that the support provided was person‑centred. This approach was clearly reflected in the care plans we reviewed.
Staff had good knowledge of people, and their approach enabled people to be as independent as possible. Staff told us the new care planning system was “more user friendly” and “easier to navigate to better support residents”.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
The management team had developed an action plan to improve the environment. The ground floor had already been refurbished, creating a more homely and welcoming atmosphere, and there was a clear plan in place to continue refurbishments throughout the rest of the home.
As part of these improvements, aspects of the ground floor layout were redesigned to enhance safety and better support residents at higher risk of falls. Equipment such as wheelchairs, walking aids, and bathing or showering aids was readily available to help keep people safe.
We reviewed records used to maintain safety within the home, including daily, weekly, and monthly checks completed by the onsite facilities team. There were no gaps in these records, and management carried out regular audits to ensure compliance.
Each person had a personal emergency evacuation plan to support them in the event of a fire and regular fire drills had taken place.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.
The management team ensured there were sufficient staff on duty to meet residents’ needs. One staff member told us, “Staffing has been a lot better since [management name] arrived. Before, there were not enough staff to support all residents, but now there are, and the senior is out of the numbers to provide additional support when needed.” We reviewed staffing rotas during our assessment, and this showed how people would be supported.
We reviewed supervision records for 2025 and 2026, which showed that staff were receiving regular supervision and appropriate support.
The new provider had also increased training opportunities for staff. As a result, training records were completed more promptly, with a higher overall completion rate.
In addition, the provider was in the process of introducing a new training platform and enhanced staff wellbeing services.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
Staff had access to appropriate personal protective equipment (PPE), and all staff could refer to the provider’s infection prevention and control policies and procedures.
Daily cleaning checks were carried out by the housekeeping team, and these were routinely checked by senior staff.
Some redecoration work had already been completed, while other areas of the building still required further work. However, this was in progress, supported by a refurbishment plan that outlined the remaining tasks and their expected timescales.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.
The management team had introduced robust systems to ensure medications were managed safely within the home. We reviewed training records, which showed that staff had received appropriate medication training. We also reviewed competency assessments, which were completed after training and included direct observations and knowledge checks before staff were permitted to administer medicines independently.
People’s medication administration records (MARs) were reviewed, and we found that individuals were receiving their medicines in line with prescribing guidance. The home was supporting people to manage controlled drugs, and these were managed in line with regulations.
The home worked closely with external healthcare professionals to keep medication care plans up to date and ensure they were reviewed regularly. This process also involved the person, or their relative where appropriate, and any changes were clearly communicated to the staff team.