Nightingales Residential Care Home

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 remained Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to Safe Care and Treatment and Fit and Proper Persons employed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff listened to concerns about safety and investigated and reported safety events. However, lessons were not always learnt to continually identify and embed good practice.

There was no overall analysis of accidents, incidents and falls. During the inspection the registered manager introduced a falls tracker to help identify if there were any themes or trends across the home or with individuals. Accidents and incidents were recorded and copies were kept with people’s care plans. These gave details of what had happened. However, whilst some included information about actions taken immediately they did not always include details of what had been implemented to prevent a reoccurrence. There were no audits or reviews of accidents and incidents to identify any themes or trends across the service, which could be addressed to reduce the risk of further accidents or incidents of a similar nature. This needs to be improved to ensure lessons are learned to reduce the risk of reoccurrence and help maintain people’s safety.

Staff understood their responsibilities in relation to accidents and incidents. They told us what actions they would take, this included contacting health care professionals or emergency services when relevant. They explained how they would always report to the registered manager or most senior person on shift. They told us they would also complete an incident form and update the person’s daily notes with details of what had happened.

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.

Before people were admitted to the home an assessment was completed. This helped to ensure people’s needs and choices could be met. It also helped ensure there were enough staff and staff had the knowledge and skills to meet people’s individual needs.

The registered manager told us it had been identified that changes were needed to the pre-assessment process. A new assessment form had been implemented and this helped ensure all aspects of people’s needs and wishes were explored.

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. However, improvements were needed to ensure staff understood how to report safeguarding concerns externally.

People’s relatives told us their loved ones were safe at the home. One relative said, “I believe [name] to be safe there.” Another relative told us, “I believe my mother to be safe here and I think she feels it as well, which is why she is so much more settled now.” Staff received safeguarding training, they told us what actions they would take if they believed someone was at risk of harm or abuse. They said they would report to the registered manager or the most senior staff member on duty. However, not all staff were able to tell us what actions they would take if it was not appropriate for them to report their concerns internally. This is an area the provider and registered manager needed to review to ensure staff had the relevant information to help maintain people’s safety.

The registered manager told us how they identified concerns and where appropriate they were referred to the local authority safeguarding team. They told us, “I may over report but I think it is important to share any concerns.” There was a safeguarding tracker which enabled the provider and registered manager to identify ongoing safeguarding’s, conclusions and outcomes.

Safeguarding information was displayed in communal areas and whilst primarily in place for staff, information was accessible to people and visitors. This included information about what action should be taken in the event of any safeguarding concerns and included contact numbers for the local authority safeguarding team.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments did not include all the guidance staff need to help keep people safe and ensure they received consistent care. Some people had been assessed as at risk of developing pressure damage. Care plans informed staff if people required regular position changes they also stated staff were to complete a document daily to demonstrate if people had developed signs of pressure damage. These had not been completed and there was no information in daily notes to show people’s pressure areas and skin integrity had been checked.

Information within Positive Behaviour Support plans identified how people may express themselves but they did not include specific guidance of how to support people when they were distressed or angry. Whilst triggers were identified there was no information about how to manage or avoid these triggers. Guidance stated give reassurance but did not include details of what this reassurance would look like for each person.

People’s mobility had been assessed and there was information in the care plans and risk assessments about the support people needed. However, this did not match the information staff gave us. Staff told us about the specific equipment and procedure used to support one person, this information was not included in the care plan.

Staff knew people well and told us how they ensured people’s safety, for example checking people’s skin integrity when providing personal care. We observed people being supported safely when moving around the home. However, people were exposed to risks as care plans and risk assessments did not contain detailed or sufficient information on how to manage individual risks.

The provider did not always detect and control potential risks in the care environment.

We identified an area of risk in the environment that had the potential to cause harm to people. There were no window restrictors in place on upper floor windows. Risk assessments had not been completed to identify if anyone was at risk of leaving or falling from a window.

Following our first visit installation of window restrictors had commenced. A system was introduced to check these monthly. This is an area that needs to be fully embedded into daily practice.

There was a system to ensure the home and equipment was maintained and serviced. There were regular servicing contracts which included electrical safety and fire risk assessment. Checks took place to ensure a safe environment was maintained. These included fire safety and water temperature checks. We saw records for the water temperature checks from February 2025. We received reassurances from staff that these were completed monthly and any concerns were addressed however, these records were not available to view.

Staff received fire safety training and fire drills were undertaken to ensure staff knew what actions to take in an emergency. Each person had a personal emergency evacuation plan to guide staff in case an evacuation was required at any time.

The provider did not always make sure appropriate recruitment checks were completed before staff started work at the home. There were enough staff who had received the appropriate training to support people safely.

We identified criminal record checks and appropriate references were not in place for one staff member. There was no risk assessment to demonstrate how this staff member was able to safely work with people. The criminal record check for this staff member arrived during the assessment. Full employment histories were not in place for each person, gaps in employment had not been identified or explored. The registered manager told us this shortfall had been identified and work had commenced to gather the relevant information. We identified these as areas that need to be improved and developed and fully embedded into everyday practice.

When staff started work at the home they completed a period of induction to introduce them to people and their care and support needs. There was a training program which staff completed and was regularly reviewed and updated. Following training, staff completed knowledge checks to demonstrate their understanding.

The registered manager told us they ensured there were enough staff working each shift to meet people’s needs. This included care staff, activities staff, a housekeeping and laundry team, chef and kitchen assistant. There were senior care staff to support the registered manager and were responsible for managing the shift. Some staff had received extra training and were able to cover other roles. For example, some ancillary staff were also able to undertake caring responsibilities. The registered manager explained this flexibility reduced the need for agency staff.

People’s relatives told us there were generally enough staff but on occasions they felt more staff were needed, this was reiterated by some external professionals and staff. Staff told us there was generally enough of them to support people safely. However, on occasions more staff were required. One staff member said, “At the moment there are enough of us, but when the home is full we sometimes need more staff in the morning.” During our inspection visits we saw staff attended to people in a timely way and provided support as required.

The registered manager told us they would continue to monitor staffing levels to ensure the appropriate number of staff are working each shift to meet the changing needs of people living at the home.

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.

The home was free from odours and clean and tidy throughout. One relative told us their loved one’s room was, “Always kept clean and tidy.” There was a dedicated housekeeping team, staff understood their own roles and responsibilities related to the cleanliness of the home and the prevention of infection. They were seen to be attentive to detail and any areas that required cleaning were attended to promptly. One staff member said, “We’re always looking and checking, even though something has been cleaned it doesn’t mean it’ll stay that way for long.” There was an appropriate system to ensure laundry and people’s clothing were managed safely to reduce the risk of cross infection and also to ensure people’s clothing was cared for respectfully. Personal protective equipment (PPE) was available throughout the home and staff were observed to be using it appropriately.

The provider did not always make sure that medicines were managed safely.

We found areas of medicine management that need to be improved. One person was self-medicating some of their medicines. We saw one of these medicines was not stored safely within the person’s bedroom. A risk assessment had been completed which stated the person was safe to take their own medicines. However, there was no information about how this would be monitored to ensure the person remained safe. There was no system for staff to monitor the amount of medicine the person was taking. This left people at risk of not receiving their medicines safely.

There was a policy for staff to follow when they needed to add medicines to the electronic medicine administration record (eMAR), for example, adding verbal instructions from a GP. This included ensuring two staff were given the verbal instruction and this was to be followed up with written instructions by email. However, the policy had not been followed, staff told us one staff member usually took instructions and there was no evidence that written follow up instructions were received.

These issues left people at risk of harm as medicines were not always managed safely.

Other aspects of medicines were managed safely. Medicines were ordered, administered and disposed of correctly. Only staff who had received medicine training and been assessed as competent gave people their medicines. Staff competency was checked to ensure staff continued to follow the correct procedures. Medicine administration records were completed when medicines had been given. Where people had been prescribed ‘as required’ (PRN) medicines there were protocols in place to guide staff to ensure medicines were given safely and consistently. There were pictorial pain charts available which staff told us they could use to support people communicate if they were in pain and ensure appropriate actions were taken.