Castor Lodge 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.

This is the first assessment for this registered service. This key question has been rated 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 people’s safe care and treatment at the service.

Risk assessments and care plans were not always clear or up-to date to guide safe practice. We found there was a lack of evidence in daily records that staff were responding to people’s needs. Daily records did not always reflect that care was provided in line with the person’s care plan. Some areas of medicines management required improvement.

However, people and relatives told us they/ their family members were safe and well cared for. People felt concerns were acted upon quickly and effectively. Staff understood the processes to safeguard people from abuse. We found there were enough staff to support people safely, and staff received relevant training. The environment at the service was safe and equipment was well maintained.

This service scored 59 (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 always have a proactive and positive culture of safety. Risks to people were not always used to learn and improve.

We found the lack of consistency in daily records and care plans meant that it was hard to monitor trends and learn lessons about how best to support people.

We carried out an inspection at another of the provider’s care homes during November 2024. During that inspection we found similar themes and issues which did not demonstrate the provider undertook prompt reviews of their other service locations to ensure effective action was taken and lessons were learnt.

There was recording of lessons learnt following an incident or complaint, safeguarding and incident analysis was completed to identify trends. Lessons learnt were discussed in staff meetings and the minutes were shared with the whole team. However, lessons learnt, and actions recorded were not always specific. For example, following 1 incident the learning was to, “improve communication” but there was no record of how this would be done. We also found there was not always a due date or sign off date for actions.

People living at the service and their relatives told us if they had any concerns that staff would listen to them and take the necessary action. However, some people told us that they did not know who to complain to and didn’t have any information about the complaints process.

However, the home manager was able to give us examples of learning from incidents. For example, for a person who could become distressed at certain times of the day, staff identified that by using the care home’s contemplation room for some quiet time with their favourite TV show improved their wellbeing.

Staff told us that senior staff were approachable and listened to them.

We saw evidence that people received a full response to a complaint and concerns were addressed.

The home had a clear and detailed central “smart” action plan with who was accountable for actions and timescales.

We found people’s safety was not always well managed and monitored.

We found care plans difficult to navigate and found conflicting and out of date information about people’s needs. We found that following a hospital admission people’s care plans were not always updated or reviewed to reflect any changes in their needs.

We found staff were not regularly recording the food consistency of people on modified diets. Daily records did not always reflect that care had been provided in line with the person’s care plan and guidance from the Speech and Language Therapy (SALT) team. For example, we found the daily records for 2 people recorded occasions where meals had been served that were a different consistency than had been recommended. This put people at risk of choking.

However, evidence of health records and appointments along with discharge information was kept in people’s electronic records for example assessments from SALT and GP reviews. We saw evidence of referrals made to relevant professionals when required. The care planning system had the ability to download people’s information and print it off when they had a hospital admission.

The care home manager was able to explain the process to ensure a smooth process when people moved in and out of the home. Relatives told us that they were informed of any referrals, appointments and hospital admissions.

We found that the provider had not always documented the decision-making process when restrictive measures were in place for example the use of bed rails and stair gates. We also found that Mental Capacity Act assessments were not always in place when they should be. We found information about people’s mental capacity impersonal and confusing and Best Interest assessments did not outline the different options considered and the least restrictive options.

However, every person and relative we spoke with were clear that they felt safe at the home and felt that concerns were acted upon quickly and effectively. Staff could tell us how they would spot signs of abuse and how to report concerns. Records showed that all staff completed appropriate safeguarding training. Staff understood the importance of gaining consent and people not having unnecessary restrictions.

We found that risk assessments were not always up-to date and contained confusing and conflicting information. This included information on the number of staff required to support people with safe transfers and the frequency someone needed support to change position to prevent pressure ulcers. We found that staff did not often record information around people’s feelings, expressions and emotions.

However, people felt that staff managed risk well, making referrals to other services when required. People told us that their needs were met, and support was increased when required.

Leaders and staff told us that as well as risk assessments in people’s care plans, they also had daily meetings where any risks were discussed, including updates following referrals and appointments. Staff told us about the electronic system in place that alerted them when there were important updates regarding risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us they felt safe in the environment and had the equipment they needed. People and relatives spoke highly about the environment calling it “beautiful” and “stunning”.

We observed the environment to be safe and well maintained. All areas of the service were accessible with wide door access and lifts available to each floor. Stairs and fire escapes were all clear and well lit. The environment was found to be pleasantly decorated and spacious.

Records regarding management of premises including fire and electrical safety were up-to date and environmental audits raised no concerns.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff files contained all the required documentation and safe recruitment checks had been completed. We observed staff interacting well with people, being attentive and responding to people’s needs.

Staff we spoke with demonstrated they had the skills and experience to provide safe care and confirmed they had appropriate training and support.

Rotas showed that staff numbers were rostered as required according to the service’s dependency tool.

Leaders completed staff meetings, observations and supervisions although it wasn’t clear from staff feedback or records how frequently these were. We saw evidence that the service was addressing this by implementing schedules to increase the frequency of these. However, they hadnotbeen fullyembedded at thetimeofassessment.

People told us they saw “regular” staff and felt they had the right skills and experience. However, some people and relatives and 1 member of staff felt that more staff were needed. Two people told us that staff could be rushed, and 2 relatives felt staff had less time to spend with people.

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.

Staff confirmed that Personal Protective Equipment (PPE) was always available, and we found the service was clean and free from unpleasant odours. Staff were trained and followed good infection prevention and control (IPC) measures. Effective cleaning and waste management systems were in place and infection control and best practice information was on notice boards. Comprehensive IPC audits were completed and there was an IPC champion to promote best practice. We observed staff wearing appropriate PPE and cleaning bathrooms after they were used.

The service did not always ensure that medication care plans were up-to date. For people with complex care needs care plans did not contain evidence of regular comprehensive reviews. We found there was contradictory information regarding self-administration of medication. We also found anticipatory medicine protocols were not held within care plans with direction. The service had already started to address these issues, but they had not been fully embedded or effective at the time of assessment.

The medication audits identified errors that needed addressing and were recorded in an action plan. However, actions taken were not always recorded and not always completed by the due date.

However, people told us they were given their medication on time and had no concerns. One person said, “I know them [medications] all and its spot on every time”.

Staff advised what actions were taken following a medication error. Staff confirmed they received medication training; competency checks and were confident in the medication processes and procedures.