Castleholme Lodge

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 service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The management team focused on a strong learning culture at the service, and robust analysis of incidents had resulted in service improvements. Accidents and incidents were reviewed promptly and investigated thoroughly by the management team. This included discussions with staff who were involved and shared outcomes with the wider team. People’s care plans and risk assessments were updated based on these reviews if necessary. 

Staff, people, and relatives had opportunities to share feedback, which included safety events, and they were listened to. Records showed meetings were held regularly with all staff groups, people, and their relatives to discuss and share information, and embed improvements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were well-established systems and pathways in place to support continuity of care and partnership working. The service carried out their own internal multi-disciplinary team (MDT) meetings and worked closely with other healthcare professionals. Appropriate referrals were made to other services such as GP’s, mental health teams, and podiatrists.

Communication between staff and healthcare professionals was effective. Staff were proactive in escalating concerns and sharing information about changes in people’s health, enabling timely input and intervention.

Staff followed direction from external professionals and implemented care and rehabilitation plans which monitored and adapted people’s support if their needs changed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately with the local authority and sent timely notifications to the Care Quality Commission (CQC).

Staff had completed safeguarding training, had a good understanding of their responsibilities, and knew how to identify and escalate safeguarding concerns to senior staff.

Deprivation of Liberty Safeguards (DoLS) applications were made appropriately where required, and authorisations were in place to ensure any restrictions were lawful and in people’s best interests.

People and their relatives told us that they felt safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were involved where possible in their care planning and assessment of risk, which included areas such as falls and malnutrition, along with specific activities, such as swimming. This enabled people to enjoy experiences that were important to them while risks were carefully considered and managed.

Risk assessments were observed to be reviewed routinely and updated promptly following incidents, and any changes were shared with the team during handover and via email.

Care plans were split into 4 sections to support staff to follow them clearly, whilst offering a fully holistic oversight of care needs and risk.

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

The building was large, spacious, and accessible for the needs of people using the service. People had access to a range of communal areas, as well as quieter spaces and outdoor areas which contributed to their comfort and wellbeing.

Effective systems were in place to ensure the premises and equipment were safe, which included regular maintenance checks to meet health and safety regulations.

Fire safety arrangements were well organised, with regular checks and testing of equipment, alongside staff training and drills to ensure staff understood their roles in an emergency. Personal Emergency Evacuation Plans (PEEPs)were in place, accessible, reflected people’s individual needs and provided clear guidance for staff.

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 were recruited safely and the provider carried out pre-employment checks to help ensure staff were suitable for their roles.

Staffing levels were planned and monitored by the deputy manager daily. Staff rota’s, feedback from people, and observations, identified enough trained staff were deployed to provide safe, effective care. The provider had a system in place which enabled unallocated shifts to be picked up by a central bank of staff, who worked across the providers other locations also. Agency staff were only occasionally utilised, which ensured staff consistency across the service.

Several staff had additional roles as champions in specialist areas which helped promote best practice and maintain high standards of care across the home.

Staff had monthly supervisions with management with 100% compliance at the time of the inspection. Thorough appraisals were carried out annually as per policy.

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 had completed Infection Prevention and Control (IPC) training and understood how to reduce the risk of infections spreading by following IPC procedures, such as using personal protective equipment (PPE) and following stringent hand-washing techniques.

Audits and checks were in place to monitor the cleanliness of the service, and the service had an IPC champion who supported colleagues in the delivery of robust IPC measures.

Kitchen hygiene was managed well, and the local authority had awarded the home a five-star rating in food hygiene.

The provider made sure that medicines and treatments were safe and met people’s needs,capacitiesand preferences. Staff involved people in planning, including when changes happened.

Medicines were stored safely and staff followed clear processes to ensure medicines were available when required. Stock was reviewed and replenished appropriately, and systems were in place to monitor balances, with management oversight.

Controlled drugs were managed safely, and medication administration records (MARs) contained all key information, such as allergies.

Medicines were administered as prescribed and ‘as and when’ (PRN) medication policies and guidance was in place to support staff.

Regular audits were completed to monitor medicines management, and action was taken to address any issues identified.

We identified a lack of recording of recorded patch rotation sites for one person and another person’s dose of PRN paracetamol not being fully completed on the MAR. These issues were raised immediately with the deputy manager who took immediate action.