Royal Court Care Home

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• 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

During our assessment of this key question, we found concerns around the culture, the governance and leadership of the service which resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. The service did not have a positive culture that was person-centred, open, inclusive and empowering. The service did not have an effective quality assurance system. The provider did not have sufficient oversight to monitor the quality and safety of the service and to ensure there was effective leadership in place. We received mixed views about the quality of the care provided from relatives. We found people were not always supported to have maximum choice and control of their lives because choice was not always actively promoted. The quality of people’s care records and risk management required improvement. The provider had not ensured that safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

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 service did not have a positive culture that was person-centred, open, inclusive and empowering. Some staff felt unable to express their views due to concerns about confidentiality. During our visit we observed staff not maintaining people's confidentiality.

The provider did not have sufficient oversight to monitor the quality and safety of the service. The quality monitoring visits undertaken by the nominated individual did not identify concerns identified during our assessment. The provider had failed to learn lessons and take action to improve the service since our last inspection.

There was not an inclusive culture at the service. Some staff raised concerns about the leadership of the service and the lack of confidentiality.

The provider was aware of the issue of poor culture within the service which had resulted in disciplinary action and dismissal of staff. The provider told us they had completed staff meetings to address this issue. Poor culture may affect the quality of people's care and have detrimental impact on staff. Our findings during the assessment showed further action was required to ensure people always experienced person-centred care.

People and relatives spoken with told us they had not been invited to attend any resident and relatives meetings or asked to fill in survey. This showed the systems in place to actively seek people's views required improvement. Relatives were aware of the service's complaints process. People felt they could express their views to staff if they had any concerns. We found people were not always supported to have maximum choice and control of their lives because choice was not always actively promoted.

Staff knew about whistle blowing procedures. This meant staff were aware of how to report any unsafe practice but some staff did not feel they could raise concerns due to lack of confidentiality. During our visit we observed staff not respecting people's confidentiality.

Managers had a good understanding of equality, diversity and human rights.

Equality and diversity was promoted, and the causes of any workforce inequality were identified and action was taken to address these.

The service did not have an effective quality assurance system. The quality of some audits undertaken was poor. As a result, the quality of the service had not been improved since the last inspection. The provider did not have sufficient oversight to monitor the quality and safety of the service and to ensure there was effective leadership in place.

The registered manager and deputy manager carried out checks to assess and improve the quality of the service provided. However, the daily walkabouts completed by managers did not reflect the concerns we found on the first day of our site visit. Audits in relation to medicines, bed rails and IPC were in place, but they did not identify concerns found during our assessment.

People's assessments needed to be more detailed to ensure all their needs were identified. The quality of people's care records and risk management required improvement to enable effective information sharing between the service and healthcare professionals.

We received mixed feedback from partners. Two healthcare professionals gave positive feedback about the service during our site visits. The local authority shared concerns about the quality of care and safety of people using the service.

Staff told us that a variety of health and social care professionals were involved in supporting people.

We received mixed views from relatives about the quality of care provided to their family member. Comments included, "They [staff] should be keeping you informed and following up more robustly on physio and the Occupational therapist" and "Staff are not understanding people’s needs, they should think what if it were their gran receiving this type of care."

The systems in place to ensure accident and incidents were appropriately reviewed so lessons were learned was not always effective in practice. There were no incident forms or records completed for the choking incident we observed. The person's daily records stated they had breakfast with no mention of the incident. The care plan audit completed in January 2024 included one care plan. The provider had not ensured that safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

The management team understood their duty of candour, to be open and honest when things went wrong. They had a system in place to monitor incidents and accidents so lessons could be learned. We found the system in place was not effective in practice.