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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement. The service was in breach of legal regulation in relation to governance at the service. 

This service scored 36 (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 vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, they did not always fully understand the challenges and the needs of people and their communities. Although the provider had some systems in place such as staff meetings and feedback surveys to encourage the involvement of people, their relatives and staff, the information gathered had not been used to drive improvement in ways that mattered to people.

The manager was visible in the service and known to people and staff, however they demonstrated limited understanding of their role and responsibilities. They had not identified and/or acted on the issues we identified during our assessment

People told us they generally felt able to speak up, and surveys had recently been introduced to gather feedback in place of resident meetings. The manager reported having an open-door policy, and most people and staff said they found the management approachable and responsive.

However, there was little evidence that staff or people were genuinely involved in shaping improvement and development of the service. Meeting minutes did not show that staff were given opportunities to share ideas or raise concerns, and there was limited evidence that any feedback led to meaningful action.

Staff told us they were happy in their work, however, there was limited evidence staff were actively encouraged to share ideas or feedback on their work to improve the quality of the service.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Systems for identifying, capturing, and managing organisational risks were ineffective and did not highlight the concerns we found. For example, high-risk items identified by external professionals, such as fire safety actions, had not been completed. The provider did not always ensure medicines were managed safely or that associated records complied with guidance. Regulatory requirements to notify CQC of notifiable events were not met because information was recorded incorrectly. These notifications were submitted only after our assessment. We were not assured that the manager or provider had effective oversight of the service. Management and staff did not demonstrate an understanding of good quality assurance principles, and the service lacked clear drivers for improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Referrals to other agencies were not always completed timeously due to poor recording practices. The manager improved these after our feedback. The manager shared plans to involve local schools for reminiscence activities and Christmas carols.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Systems and processes were applied inconsistently, with no clear audit schedule or effective quality assurance in place. The management team did not demonstrate oversight or implement action plans, despite repeated concerns raised during previous inspections. This reflected a continued lack of accountability and improvement. The provider and manager did not fully understand the principles of good quality assurance and were unable to consistently identify areas for improvement. This resulted in missed opportunities to address safety shortfalls. There was little evidence of learning, reflective practice, or service improvement.Information to support performance monitoring and decision-making was unreliable or not collected. For example, incidents and accidents were not always recorded or reviewed effectively to identify patterns or triggers requiring action. We saw no evidence of learning from incidents in staff meetings or supervisions.