CQC report explained · a residential care home
What the CQC found at Castlecroft Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe and there were enough staff. However, some medicines given only when needed did not have clear protocols, and safeguarding incident trends had not been reviewed to see whether actions had worked.
- Effective?
- Good
- Staff had training, induction and regular support. People were offered choices, received suitable food and drink, and were supported to access health professionals. Some records did not explain who had been involved in decisions made for people unable to decide for themselves.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. Inspectors saw staff protecting privacy and dignity, offering choices and supporting people to remain independent.
- Responsive?
- Good
- Care was generally adapted to people's needs and preferences. People had access to activities and social contact, and relatives said concerns were dealt with, although some feedback had not been recorded.
- Well-led?
- Requires improvement
- The management team was approachable and had links with community and health professionals. However, audits had not identified shortfalls in care records, risk assessments and medicines information, and an improvement action plan had not been updated for five weeks.
What inspectors found, May 2018
Castlecroft Residential Care Home was rated Good overall, but Requires Improvement for being well-led.
The inspection was unannounced on 15 March 2018. Inspectors returned to speak with staff and health professionals by telephone and email on 23 March 2018. They spoke with people living at the home, relatives and staff, observed care, and checked care records, medicines, staffing and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. People and relatives spoke positively about the care. Inspectors saw kind and respectful interactions, enough staff, support with medicines, suitable food and access to health professionals.
The home was rated Requires Improvement for Well-led. Its audits and checks had not found important problems with risk assessments, care plans and some medicines information. Some records were inconsistent or not up to date, and earlier concerns about monitoring improvements had not been fully resolved.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed kind, compassionate interactions and saw that privacy and dignity were respected.
“We saw interactions between staff and people were kind and compassionate and staff had a supportive approach.” from the report
Enough staff
People and relatives said there were enough staff to meet people's needs. Staff changes were not frequent, helping staff know people's preferences.
“People told us there were enough staff to meet their care and support needs.” from the report
Food and drink
People had meal choices, could ask for alternatives and had access to drinks during the day. Staff knew about dietary needs and preferences.
“Food and drinks were available throughout the day to encourage people to eat and drink as much as they liked” from the report
Activities and community links
The home provided activities, individual time and trips into the local community. Volunteers, nurseries, colleges, universities and churches were involved.
“We saw residents enjoying this company and interaction.” from the report
Care records and risk assessments
needs fixingSome care records were not consistent, current or person-centred. Risks were not always fully assessed, managed and reviewed, including triggers and responses to behaviours that may challenge.
“We found systems in place did not ensure care records were reflective of people's current needs and how to meet them.” from the report
Medicines given when needed
seriousSome people did not have clear protocols explaining when medicines prescribed for use only when needed should be given. This could make decisions less consistent, especially for new or temporary staff.
“There were not always protocols (plans) for the administration of these medicines to make sure they were administered safely.” from the report
Quality checks did not find problems
needs fixingThe home's audits and the resident-of-the-day checks failed to identify several shortfalls. Earlier concerns about records and quality monitoring had not been fully improved or sustained.
“At this inspection, we found there had not been improvements made in relation to these areas” from the report
Safeguarding incidents were not reviewed
seriousThe home had identified a pattern in incidents involving altercations between residents and introduced activities. It had not checked whether this action reduced the incidents.
“However, there had not been a review of this analysis or action implemented to see if it had worked in reducing the number of altercations between residents.” from the report
Some feedback was not recorded
minorPeople and relatives could raise concerns, but some concerns raised with managers had not been captured in the records. A risk assessment linked to an environmental issue had also not been updated until after the inspection.
“However, some people and their relatives also told us about concerns they had raised with the deputy manager and registered manager and this feedback had not been captured.” from the report
- 01What has been done to make sure every person's care plan and risk assessment is current, consistent and person-centred?
- 02How are medicines prescribed for use only when needed managed, and does each person now have a clear protocol?
- 03How do you check whether actions taken after altercations between residents have reduced the number of incidents?
- 04How are concerns and informal feedback from people and relatives recorded and followed up?
- 05Has the improvement action plan been updated, and how do managers check that changes are sustained?
This was a planned inspection covering all five key questions, with an unannounced visit on 15 March and follow-up conversations on 23 March 2018. This explanation was written from the published report of 11 May 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Castlecroft Residential Care Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- May 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Castlecroft Residential Care Home →
- January 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- July 2013
Registered with the Care Quality Commission on 1 July 2013.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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