Castle Donington Nursing Home

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• 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

The provider’s governance systems were not always effective in identifying or addressing shortfalls. Staff were well-supported by the registered manager who was approachable and committed to continually improving the service. Some of the ways risks were managed had improved.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff felt supported by the management team. A staff member told us, “Staff morale is good here because we are supported well by management. The [registered] manager has an open-door policy, and you can speak to the manager whenever you need to.” Another staff member said, “If I feel the need to talk to the [registered] manager I can approach them at any time. I feel very supported in my role. If I need help, I get the support. I have regular supervisions too where we can openly discuss any concerns they may have.” Staff felt their concerns were addressed by managers in a timely manner with good outcomes. A staff member told us, “I reported an incident recently. It was dealt with swiftly. I was asked to complete all relevant paperwork on the day. The [registered] manager then told me that the incident had been reported to the relevant people.”

The provider’s quality assurance audits and checks were not always effective. A safeguarding incident occurred and although staff took action to prevent a re-occurrence this was ineffective. A person’s risk assessment was not robust enough to protect people from harm. At the time of our visit these incidents had not been analysed and there was no record of any lessons being learnt. Following our visit the registered manager contacted us to say they were holding a ‘lessons learnt’ meeting to identify actions that could have been implemented at the time. This meant they were addressing this issue. Medicines audits failed to identify the concerns we found in relation to ‘time critical’ medicines, monitoring of blood sugar levels, and reviews of people on covert and/or ‘as required’ medicines. The service’s medicines audits had not identified these shortfalls. Following our visit the registered manager contacted us to say all these shortfalls had been addressed and new systems put in place to prevent any re-occurrence. At the time of our visit the service had improved some of the ways risks were managed. Handover records had been updated so information about risk was shared when shifts changed. The service’s annual and bi-annual audit tool had been improved to make it more comprehensive and easier to use. Following our visit the registered manager was proactive in sending us an action plan to address all the shortfalls we found during out visit. This demonstrated a commitment to continually improving the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.