Castletroy Residential 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 Good. At this assessment the rating has changed to Inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment and safeguarding.

This service scored 28 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider did not effectively identify where lessons could be learned. Systems were not effectively implemented to ensure incidents were recorded,analysed or responded to appropriately.

The registered manager was not aware of ongoing incidents occurring in the service that put people at risk of harm. Insufficient action had been taken to ensure these incidents were escalated or recorded appropriately to enable reflection and learning to take place.

There was limited oversight of incidents and when incidents had been reviewed by senior staff insufficient action had been taken, for example incidents related to people’s emotional distress and unexplained injuries were not reviewed adequately. This meant patterns and trends relating to people’s care needs and risks were not identified or acted upon.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

The provider did not ensure adequate information was gathered and recorded about people before they came to live at the service. We reviewed pre assessment documentation that had been completed by the registered manager before the service began providing people’s support and saw they had not been appropriately completed. Important sections of these documents were blank, for example special dietary needs and preferences and people’s health needs.

The failure to complete thorough pre-admission assessments placed people at risk of not having their care needs met in a safe,appropriate way. Failure to assess people’s needs prior to admission also meant that the service was not ensuring they could meet that person’s needs if the person was admitted.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider had not always ensured staff followed safeguarding policies and procedures. This meant incidents had not always been investigated. Nor had steps been taken to mitigate future risk. Not all incidents had been reported to the local authority safeguarding team as required. Following the inspection,we reported safeguarding incidents for 7 people to the local authority.

However, people living at the service told us they felt safe and comfortable with the staff who supported them. One person said, “I fall asleep at night, and I don’t have anything to worry about.” Another person’s relative told us, “I have no concerns about [Person’s] safety or wellbeing.”

Staff told us they had received training in safeguarding adults and knew where the safeguarding policy was, they explained they would report any safeguarding concerns to the management team, who would need to report this externally. However, we found this had not always happened in practice.

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

Staff did not have clear guidance on how to support people safely. Care plans and risk assessments were inaccurate and inconsistent in relation to people’s moving and handling, mobility, skin integrity, nutrition and health conditions.

Two people’s skin integrity assessments contained unclear information about the condition of their skin and injuries they had sustained, including pressure injuries, moisture lesions and skin tears. It was not possible to determine from the information provided, which injuries were current and therefore what care was required.

Another person’s nutrition care plan identified they were at high risk of choking and should be provided with a modified diet. However, this care plan also stated that the person liked foods that were not compatible with this type of diet; there was no guidance on how these foods should be prepared to ensure they were in line with the diet assessed as safe for the person or if the person had been involved in any discussions regarding their diet.

One person’s mobility care plan stated they were at moderate risk of falls and had no known history of falling in the previous 12 months. We reviewed incident logs and saw that in December 2025 the person had experienced an unwitnessed fall. Another person’s safer handling plan stated they did not require the use of a hoist to transfer, staff told us and care records confirmed the person sometimes required the hoist to help them transfer. This meant the person was at risk of receiving unsafe support to move.

People’s’ personal evacuation plans were confusing and did not provide sufficient information. There was a risk people would not be evacuated safely in an emergency.

Records showed that staff did not consistently follow the care plans and risk assessments in place when providing care to service users. Skin integrity assessments for 2 people identified they were at risk of developing pressure injuries or moisture lesions. Staff were directed to monitor positional changes every 2 hours, however, records showed both people were not supported to reposition in line with their care plan overnight, as gaps between repositioning were consistently longer than 2 hours.

The failure to assess and support people to manage known risks in their lives placed people at risk of not receiving safe care.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider had failed to adequately manage fire risks. Senior staff were unaware of the content of the fire risk assessment in relation to the evacuation of the home in the event of a fire and described unsafe practice when evacuation procedures were discussed with them. Six monthly fire drills were being carried out; however, we could find no records of a full evacuation practice being carried out, staff confirmed these did not happen. Service users and staff were at increased risk of harm if there was a fire emergency at the service.

The provider failed to monitor and mitigate risks from the environment and equipment. Environmental checks were scheduled to take place monthly, however, at the time of the inspection, no environmental checks were available for January 2026. These checks included regular checks of hot water, door guards, maintenance checks and cleaning schedules. The failure to maintain regular environmental checks placed people at risk of harm.

We saw that wooden blocks had been fixed to peoples’ bedroom walls to prevent their beds from damaging the walls and plug sockets. This created a gap between the bed and the wall that posed a risk of entrapment to people. In an attempt to mitigate this risk, we saw a duvet had been rolled, taped up and placed along the wall side of the bed, there was nothing to hold this securely in place and there continued to be a risk of entrapment. No referral had been sought for specialist advice or equipment provision to mitigate this risk safely or appropriately.

The provider acknowledged the findings of the assessment in relation to environmental safety. They began to implement the actions required to make improvements during the assessment. However, these risks had not been previously identified by the provider, this had negatively impacted people’s experiences of living in the home.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff had not received the training required to ensure they were able to effectively meet the needs of the people they supported. Training records demonstrated that staff had not received suitable training in all the areas necessary for their role.

Staff were supporting people with dementia, some of whom physically resisted staff support with personal care, staff had not received the training they required to enable them to do this safely. Many people in the home were at high risk of falls, at the time of the inspection only 12 out of 47 staff had received training in falls prevention. Staff were providing support to people who had a diagnosis of Parkinsons disease and epilepsy, staff had not received training in these areas.

People and their relatives told us there were enough staff on duty to meet their needs. One person’s relative said, “There always seems to be sufficient staff around.” During the inspection we saw that in the main there were sufficient staff, however at certain times of the day people had to wait for support. For example, some people did not receive personal care and were not served breakfast until late morning, and lunch was served at midday. The registered manager told us if people had eaten a late breakfast they would be offered a later lunch.

A recruitment policy was in place which supported safe recruitment practice. Staff files contained all the necessary pre-employment checks which showed only fit and proper applicants were employed.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed that some areas of the home were not clean or maintained in a way to mitigate infection risks. For example, many of the taps in service users’ ensuite bathrooms had limescale on them and some shower heads were visibly dirty and covered in limescale. Limescale on taps is an infection control risk and failure to effectively descale shower heads posed a significant water safety risk. Communal bathrooms were dirty and appeared to be used for storage, fans in people’s ensuites were dirty, with a build-up of dust and debris.

People’s toothbrushes, toiletries and other equipment were not kept safely. There was no hygienic storage for people’s toothbrushes, toiletries were stored behind people’s toilets, and we observed urine bottles on two people’s bedroom tables next to containers of drink.

Food hygiene measures were not complied with. We saw decanted food was not labelled with a date of opening and there were items past their use by date in the fridge. This meant people were at risk of eating food that was unsafe.

The provider had not implemented effective processes to protect people from the risk of infection, this placed people at risk of harm.

The provider acknowledged the findings of the assessment in relation to infection prevention and control. They began to implement the actions required to make improvements during the assessment. However, these risks had not been previously identified by the provider, this had negatively impacted people’s experiences of living in the home.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

During the inspection we observed unsafe practice in relation to the administration of people’s medicines. On the first day of the inspection, we saw that an unknown tablet had been left on the bedside table in a person’s bedroom. This person was reliant on staff to administer their medicines and was at risk of ill health if they did not receive their prescribed medicines. In addition, many people living in this area of the home were living with dementia and moved around the home independently. There was a risk the medicine could have been taken by a person for whom it was not prescribed.

Staff did not follow safe procedures in relation to the administration of controlled medicines. We saw that staff had administered one person’s controlled medicine and had not recorded the administration in the controlled medicines book.

Covert medicines were not always given in line with the instructions from the person’s GP or pharmacist. We observed a member of staff administer one person’s medicines covertly, they did not follow the instructions contained in the ‘record of GP instruction to administer medicines covertly’. The failure to administer the medicines as directed put the person at risk of an adverse reaction or the medicine not being appropriately absorbed.

Medicines audits did not result in people’s emergency rescue medicines always being in stock in the home. We reviewed the audits of medicines to be administered when required (PRN) and saw that one person’s diabetic rescue medicines had been out of stock on 2 occasions since November 2025. In the event of Hypoglycaemia, this person would require immediate treatment to prevent a serious deterioration in their condition, the failure to have this medicine in stock put the person at risk.