Castlethorpe Nursing Home

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

We identified a breach of legal regulation regarding the governance of the service. The checks and audits had not been effective in identifying issues which could compromise the safety of the service and had not driven improvement. When actions were identified, these were not completed in a timely manner. These included risks associated with fire safety and actions we identified from our previous inspection. There was limited evidence the service had a collaborative approach and utilised learning to improve the quality and outcomes for people. Staff told us they felt supported, and the registered manager was visible in the service.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were unable to tell us what the shared vision and goals of the service were. Staff attended team meetings and noted this was an opportunity to receive and share information. The registered manager told us they had an open-door policy.

The visions, values and strategy of the service had not been done in collaboration of with service users, relatives, staff and other professionals. There was a lack of learning from events, incidents and feedback to improve the service.

Although staff feedback about the management of the service was positive, there was a lack of leadership to ensure the service operated within legislative requirements. Staff noted the following, “The registered manager is always visible in the service”, and “[Registered Manager] is supportive and very friendly”.

The significant concerns raised during this assessment process did not demonstrate the provider had a robust understanding of legislation and best practice. Process had not been operated effectively to ensure that people were consistently safe and that compassionate, person-centred care had been promoted. There was no clinical lead in the service, which could have affected those who required complex nursing care.

Although the registered manager had team meetings, staff were not empowered or confident that their concerns and ideas would result in positive change. They did, however, note the registered manager treated them fairly.

The provider had a Freedom to Speak up policy.

Although the registered manager had team meetings, staff were not empowered or confident that their concerns and ideas would result in positive change. They did, however, note the registered manager treated them fairly.

The provider had an Equality and Diversity policy, and staff had received training. People from minority ethnic backgrounds told us they felt supported by the provider. Recruitment files included a health declaration so any reasonable adjustments could be considered.

The registered manager noted they used a wide range of audits and checks, but these had not been effective. Whilst some actions were taken during and following our assessment, other actions remained outstanding and limited assurances were provided about how the improvements were going to be made. The provider and registered manager did not demonstrate a robust understanding of legislation or statutory requirements.

Systems and checks had not been effective in identifying and addressing the concerns found during this assessment. We requested immediate actions on two of the highest risk areas, which were window safety and the fire risk assessment. Information we requested as part of the assessment was not readily available, up-to-date or well-organised. Some of the issues noted during this assessment had been highlighted at previous inspections and action had not been taken. This presented a significant risk to people’s safety and quality of life.

People were not supported to engage with their community. Comments included, “It is boring in here, every day is the same”, “Not much for me to get up and do, which is why I have all the tv packages” and “Not sure what we would do or could do if we went out.” Questionnaires and meetings were held to seek people’s feedback but there was no evidence to support how this had been used in the running of the service.

Staff were not aware of any wider links to the community or social groups. They did however confirm people had access to a wide range of professionals including GP’s, physiotherapists and chiropodists.

Professionals confirmed staff engaged well with them on site but didn’t have confidence they would actively share reports of deterioration. Professional feedback was not sought or used to improve the service.

There was a lack of integration within the community, which presented a risk that some people could be isolated, and their well-being affected. Processes had not identified and addressed this. There was limited evidence to support the sharing of good practice between services. The service did work with other organisations, such as health professionals.

There was a strategy in place for the recruitment and development of adaptation nurses, however there was no clinical lead in the service to support safe nursing care. The registered manager could not demonstrate consideration as to themes, trends or actions required to support people safely and to promote good quality care. The feedback provided by staff did not demonstrate the service was promoting innovative practice.

People and their families had not been involved with the development of the service. The provider did not have an improvement plan in place to demonstrate how the service was making the necessary improvements. Some of the areas identified as action points from this assessment were outstanding at our last inspection. This included staff taking part in fire drills and having a system to identify themes and trends from incidents which occurred. This did not demonstrate the provider had a robust learning culture.