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: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in continued breach of legal regulation in relation to quality assurance and governance of the service.

This service scored 54 (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 shared vision, strategy and culture that supported improvement and more consistent communication with families and friends. A clear shared purpose within the service was supported by visible leadership and regular communication. There were structured daily “Flash meetings” where all departments were present to discuss concerns and actions for the day. People and their relatives described an improvement in communication, telling us they received updates routinely, with information by text or email or a phone call.
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. People and their relatives told us the registered manager was known to them and visible in the service. The service had recently begun a programme of supported improvement, but this was not yet at a stage where it was showing the required outcomes.Actions required after our previous assessment had not been fully completed. For example, repairs to fire doors and allied safety equipment. This meant previously identified risks remained.

People did not always feel they could speak up and that their voice would be heard. People knew how to complain, and a relative said the complaints process was displayed “on a notice in the hall / foyer area.” The provider maintained a visible presence within the service and had arrangements in place for staff supervision and team meetings. Staff told us they felt able to discuss concerns with the registered manager. However, the supervision records and meeting minutes reviewed during the assessment did not provide sufficient evidence that staff were consistently encouraged or given opportunities to speak up, raise concerns, or contribute to service improvement. Consequently, we could not be assured that these forums were being used effectively to promote an open and transparent culture.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt respected, supported and treated fairly. They told us the registered manager was approachable and supportive when they had concerns. One staff member said “It is better than it was before. I would go to [Name] if I had a problem - they would listen”.

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. Leaders did not always use available information effectively to drive improvement, which reduced assurance that the service was well governed and sustainable. Some quality assurance processes were in place, but these did not always provide leaders with sufficient oversight of performance and risk. Audits and monitoring activity had not identified the concerns we found, or actions were not always followed through. For example, a person’s falls risk had been increased by the placement of a floor rug. While action was taken to reduce the risk, this example highlighted delays in implementing effective risk management controls and demonstrated that risks were not always managed proactively or consistently.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service worked with local health and social care partners and promoted community links through activities and engagement.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always 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 assessments. For example, fire safety repairs remained outstanding. 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, or reflective practice. The provider did not consistently learn from incidents, feedback or monitor activities, which limited opportunities for sustained improvement. While some learning took place, this was not always analysed in depth. Leaders did not always identify themes or evaluate whether actions taken had led to improvement. For example, audits were completed, but where actions were required, there was no confirmation that these had been completed. No follow up on the effectiveness of action taken was evident. This reduced the provider’s ability to embed learning and demonstrate continuous improvement and innovation in practice. During our previous assessment we had identified the provider had not displayed the CQC rating on their website, and we had provided guidance to ensure this was actioned. At this assessment the provider had still not added this legally required information. The provider completed this immediately after our assessment.The provider had sought support from local authority teams, and a management consultant had recently been hired to support further transformation of the service to improve outcomes for people.