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

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 Inadequate. At this assessment the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed.

This service scored 34 (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 manager had not reviewed all accidents and incidents as these had not been recorded correctly. This meant opportunities to identify themes and trends were missed, improvements had not been identified, and lessons could not be learned. The manager held a training session for staff after our first visit to ensure incidents were properly documented.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. People's care plans showed the involvement of other services, for example District Nurses, Speech and Language Therapy (SALT) and Deprivation of Liberty Safeguards (DOLS) teams. Information was available if people needed to access other health organisations. However, information regarding referrals was not easily located, meaning that staff were not always aware of changes or appointments. After our feedback the manager adapted the way these were recorded to improve monitoring and adherence.

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 service had policies about people’s rights, but staff did not understand or follow them. For example, safeguarding incidents were not escalated properly. We found multiple incidents involving a person's behaviour had been recorded in their care notes instead of in the correct forms, meaning the manager was unaware of them and could not submit required referrals and notifications. This exposed both this person and others within the service to an increased risk of harm. Following our assessment the manager reviewed their systems for recording safeguarding concerns. During our assessment, we made safeguarding referrals about the concerns we found.

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. The provider failed to identify, assess and act on risks to keep people safe from the risk of harm. For example, the provider had not assessed and managed risks relating to people's specific health conditions. For example, Diabetes. Care plans for people who had urinary catheters did not inform staff on the additional risks faced, or how to recognise these. Care plans lacked guidance for staff to follow when people became distressed and conflicting information was recorded on how to support people to move safely. This meant staff did not have the information or guidance on how to support people safely or recognise a change in their condition. The management team began updating care plans after our assessment to reduce risk and improve care delivery.

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 service did not assess or properly manage environmental and equipment-related risks. There was limited action to assess, monitor or improve the safety of the service. Reports completed by external agencies, for example Fire Risk Assessments, had repeatedly identified areas requiring action, but we found no evidence that these had been completed. The fire safety concerns identified during the previous assessment remained unresolved, including several ineffective fire doors. There was no evidence of when the required work would be completed, and no interim risk management measures had been put in place which meant people continued to be at risk in the event of a fire. To help mitigate these risks until corrective action was taken, we requested a review of Personal Emergency Evacuation Plans (PEEPs) and additional risk assessments for people using flammable creams. We also requested additional day and night checks to help keep people safe. Radiators within the service were not protected, increasing the risk of burns to people if they were to fall against them. This had not been identified by management.

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. Recruitment checks were in place, but these were not always in line with best practice. For example, gaps in staff employment history had not been fully explored. The training matrix showed staff training was not being regularly completed or reviewed by the management team. This highlighted a lack of oversight and planning to ensure staff were equipped with up-to-date knowledge to deliver safe and effective care. Staff supervision and support were inconsistent and mainly focused on tasks. Following the assessment, the management team updated supervision practices.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. During the assessment, we identified several issues related to infection control within the service. Items intended for personal care were stored incorrectly, left on the floor or placed in communal bathrooms, increasing the risk of cross-contamination. Flooring was damaged and dirty, and furniture was worn and split, meaning that it could not be cleaned effectively. Equipment used to support people to shower was unclean and showed damage. The manager removed this from use at our request. Personal protective equipment (PPE) was not disposed of appropriately. These matters had not been considered as infection control risks, and there were no records to show they had been identified or addressed. As a result, people were placed at an increased risk of exposure to infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Systems were in place to safely store, administer, and record the use of medicines. However, these were not always followed. Documentation to support the safe administration of medicines was not always in place or accurately completed. For example, when there were changes to people's prescribed medication, the instructions were overtyped, leaving no audit trail or ability to track changes. Where medication had been prescribed to be 'used as directed' or 'apply when required', there was no guidance in care plans to guide staff to safely administer the medication. This did not support safe and accountable medicine administration.