Castlethorpe Nursing 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

We identified 2 breaches of the legal regulations for safe care and treatment. Insufficient actions had been taken to ensure the safety of people living at the service. This included not identifying risks associated with single-paned windows. We reported our concerns to the provider, who took action to address this. Parts of the service were worn and unclean. Staff involved in the administration of medicines did not always have up-to-date training and their competencies were not regularly assessed. However, we observed medicines were well-organised and people told us they received them. People generally felt safe living at the service. Staff understood their duty to report safeguarding concerns.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst people could share their experiences of the care they received, there was no evidence as to how this information had been used to improve the service or people’s experiences of their care.

Staff told us handovers were used as an opportunity to share important information about residents, such as accidents or incidents that had happened. However, staff could not consistently demonstrate learning from these incidents.

The provider did not have a robust system of reviewing accidents, incidents or safeguarding to identify any themes or trends. There was limited evidence of learning from incidents, to consider what had gone wrong and how things could be improved.

People were not consistently involved in discussions about their care and completing their documentation. People did have access to health professionals, including a regular visit from a GP.

Staff had not consistently recognised or raised concerns for some people’s changing health needs. Staff shared information with people’s relatives and utilised the visiting GP. The registered manager was able to explain how they would support a safe discharge to the service from hospital.

Professionals queried how proactive staff were in contacting them to report concerns or changes to people’s presentations. Staff were noted to be kind and caring in their approach.

Actions had not always been taken when there were concerns about people’s well-being. Recommendations had not always been implemented. People did generally have care plans and risk assessments in place.

During the assessment we identified areas of concern where people had not been appropriately safeguarded. This included promotion of fire safety, window safety and infection prevention and control. People did, however, tell us they felt safe. Comments included, “If I did not feel safe, I would have left a long time ago” and, “[Person] is safe and well cared for.”

The management team had not identified potential risks and hazards within the environment and taken appropriate steps to safeguard people. Staff shared their view that people were safe. Staff understood how to raise a safeguarding concern.

We noted that most people appeared comfortable with staff. However, we observed elements of the environment and practices which were unsafe and exposed them to potential harm.

The provider did not have an effective system for reviewing safeguardings to identify areas for improvements and consider actions to mitigate the risk of recurrence. Safeguardings were recorded and shared with the relevant agencies so enquiries could be completed.

People were not always involved in the development of their risk assessments. Some relatives expressed concern about a lack of prompt action around falls and weight loss, we raised these concerns with the provider who took action to address this.

Staff and leaders had not consistently identified and responded to concerns about deterioration in people’s physical health or the concerns about the safety of the environment. People’s risk assessments were not consistently followed and recommendations from professionals were not always actioned.

People were not always involved in the development of their risk assessments. Some relatives expressed concern about a lack of prompt action around falls and weight loss, we raised these concerns with the provider who took action to address this.

Systems and processes were not effectively operated to identify and address the concerns raised during our assessment. Checks were not completed on people’s care records to ensure the necessary actions had been taken. Risk assessments were in place but lacked detail to support staff.

We received mixed feedback from people about their living environment. Some were generally happy with their rooms and felt they were kept clean and tidy. However, others complained about flies and the excessive heat.

Staff were unable to tell us when they last attended a fire drill and there was no recording of fire drills. Fire alarm tests had not been completed since March 2024. The management team failed to take timely action to address the safety of the environment.” During the inspection the registered manager implanted a new system to support him in reviewing fire safety.

The physical appearance of the building was variable. Some areas required decorating and refurbishment, whilst other areas had just been decorated. Equipment was stored safely.

The provider had not ensured the environment was safe and comfortable for people who used the service. For example, we requested urgent action plans relating to fire and window safety. Information was not always in place to support people’s safe evacuation from the building and staff did not have the knowledge to support this. At the time of our assessment there was no action plan in place to demonstrate how issues within the environment would be addressed.

We received mixed feedback about staffing. Some people said staff responded promptly to their calls for assistance, whilst others said, ‘I have to wait a long time when I press my buzzer’ and ‘I don’t feel unsafe but it takes ages for someone to answer the bell.” People consistently told us there was a lack of staff to support with activities.

The service did not have a clinical lead to provide clinical support and guidance to registered nurses. Qualified nurses were not up-to-date with all of their training. This presented a risk that people may not receive safe and effective nursing care to meet their health needs. Staff told us although there were busy periods however, staffing levels were safe.

We observed staff were available, kind and responsive towards people, however, there was limited interaction between people and staff outside of planned activities, such as mealtimes or personal care.

The provider could not demonstrate staff had received support and training to equip them for their role. CQC and the provider could not be assured the correct numbers of staff had been deployed to safely meet people’s needs as how staffing the rota’s had been calculated was overridden each month so we were unable to see how staffing had been determined on the basis of needs. Staff were recruited safely.

People gave us variable feedback about the condition and cleanliness of the service. We observed some IPC practices which were not in line with best practice and could have compromised the safety of people’s care.

Elements of staff practice did not promote consistently high standards with infection, prevention and control practice. For example, there were shared urine bottles within the sluice. Following the inspection the registered manager assured us this practice has ceased. Staff had received training in this area, but further support was needed to ensure the necessary standards were maintained. Staff told us they had access to PPE and undertook online training.

We observed bed bumpers which were worn and split and fly catchers with dead flies hanging above a person’s bed. The heating in some parts of the building was excessive. When we returned for the second day of our inspection, most of the concerns had not been addressed.

The audits and checks of the building had not been effective in highlighting and addressing the concerns found during the assessment. Limited action was taken during the assessment to demonstrate learning or address the concerns.

People did not raise concerns about medicines practice and told us they received their medicines. Elements of documentation and staff training and competency required improvement to ensure staff could safely administer people’s medicines.

Staff did not have their competencies assessed regularly and some were out of date with medication training. Audits completed by the registered manager did not identify some of the concerns we found on our assessment. This included protocols not always being in place for people prescribed ‘as and when’ medication. However, people’s medicines were well-organised and safely stored. Medicines stocks completed on the day of the assessment matched the amount recorded on the electronic system.

Audits did not identify the concerns we found on our assessment. This included protocols not always being in place for people prescribed ‘as and when’ medication. Clear instructions were not consistently in place for the administration of topical creams. These records help to guide staff practice. However, people’s medicines were well-organised and safely stored. Medicines stocks completed on the day of the assessment matched the amount recorded on the electronic system.