Castor Lodge Care Home

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.

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this registered service. This key question has been rated good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We observed staff working well as a team and with external professionals. People and relatives we spoke with told us they were involved in discussions around their care.

However, we found care plans missing important information in relation to end of life care wishes, needs and preferences.

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

This is the first assessment for this registered service. This key question has been rated good. This meant people were supported and treated with dignity and respect; and involved as partners in their care.

People told us that staff were very caring and kind and respected their individual preferences. Staff told us the importance of getting to know people they care for and building a rapport.

Responsive – this means we looked for evidence that the provider met people’s needs.

This is the first assessment for this registered service. This key question has been rated good.

This meant people’s needs were met through good organisation and delivery.

We found that people were supported with their religious and cultural needs and the home was easily accessible. We saw evidence that concerns were followed up and referrals were made to relevant health care professionals.

However, we found that end of life care planning, including guidance around anticipatory medication was not always in place. We also found that staff were not always recording people’s preferences or how they were spending their day.

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.

This is the first assessment for this registered service. This key question has been rated 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 breach of legal regulation in relation to governance at the service.

Leaders told us that risks to people were analysed in the monthly clinical governance meetings. However, it was not clear that records were updated following these meetings due to the conflicting information in care plans and risk assessments. Audits were completed regularly by leaders but failed to identify gaps we found during our assessment.

People and staff had some anxiety regarding changes in management, but everyone was clear they had a senior member of staff to speak to if they had any concerns.