CQC report explained · a nursing home
What the CQC found at Castleford Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2022
Inspected but not rated; inspectors found medicines were managed safely, but some medicines audits and infection-control practices needed improvement.
This was an unannounced targeted inspection on 11 July 2022. Two inspectors focused on how medicines were managed. They reviewed medicines records, care records, audits and incident records, and observed care and staff practice.
The inspectors found up-to-date medicines procedures, trained staff and checks that staff were competent. Medicines were stored safely and given in line with national guidance. They found no evidence that people were at risk of harm from the medicines concern examined.
The medicines audits did not always identify recording errors. A more thorough audit system was being introduced, but it was not yet fully established. Inspectors were also only somewhat assured about the safe use of protective equipment and the premises' layout and hygiene.
The home was not given a new overall rating. Its previous rating was Good, published on 17 May 2022. This inspection did not assess the whole service or the whole Safe question.
Medicines training
Staff received regular training and were assessed to check they were competent to give medicines.
“Staff received regular training and assessments were carried out to ensure staff were competent to administer medicines.” from the report
Safe medicines practice
The home had current procedures, safe storage and guidance for medicines given when needed or covertly.
“The provider had systems in place to manage medicines. Policies and procedures were in place and up to date.” from the report
Kind interactions
Inspectors saw staff interacting with people in a kind and considerate way.
“We observed staff interacting with people and found they were kind and considerate in their approach.” from the report
Medicines audits
needs fixingThe existing audits did not always find recording errors. A more thorough system was being introduced but was not yet embedded in practice.
“As these were not always effective in identifying recording errors, the provider was implementing a more thorough auditing system.” from the report
Infection-control practice
needs fixingInspectors were only somewhat assured that protective equipment was being used safely and that the premises' layout and hygiene supported safety. The provider was directed to further resources.
“We were somewhat assured that the provider was using PPE effectively and safely.” from the report
- 01How often are medicines records now audited, and how do you check that recording errors are identified and corrected?
- 02What changes have been made to the more thorough medicines auditing system since the inspection?
- 03What improvements have been made to the safe use of protective equipment?
- 04What changes have been made to the layout and hygiene practices of the premises?
- 05How has the home responded to the concerns that led to this targeted inspection?
This was a targeted inspection of medicines management and selected infection-control measures; it did not assess the whole service or the whole Safe question, and the other ratings were not reviewed. This explanation was written from the published report of 3 August 2022 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.
What inspectors found, May 2022
Castleford Lodge: Rated Good overall; safe care was found, but leadership and quality checks required improvement.
This was an unannounced focused inspection on 12 April 2022. Inspectors looked at Safe and Well-led because of concerns they had received. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe. Inspectors found enough staff to meet people's needs, safe recruitment checks, risk assessments and safeguarding knowledge. Accidents and incidents were recorded and reviewed. Some medicine records did not match stock, but the home had identified and resolved this as a recording issue.
The home was rated Requires Improvement for Well-led. Quality checks had not always found or dealt with problems quickly. Inspectors found cleaning, maintenance, food presentation and person-centred care issues. The manager acted quickly after the inspection, and a new audit system was being introduced, but it still needed to become established.
The overall rating stayed Good. This was because the inspection only reviewed Safe and Well-led. Ratings for the other areas were carried over from an earlier comprehensive inspection.
Safeguarding
Staff understood safeguarding procedures and knew what to do if they suspected abuse.
“Staff we spoke with were knowledgeable about safeguarding protocols and knew what action to take if they suspected abuse.” from the report
Risk management
Risks linked to people's care were identified, with plans in place to reduce them. Equipment and premises maintenance were also checked.
“Risks associated with people's care were identified and risk assessments were in place to mitigate risks.” from the report
Learning from incidents
The home recorded and reviewed accidents and incidents to look for patterns and reduce future risks.
“Accidents and incidents were recorded and analysed to identify any trends or patterns.” from the report
Kind interactions
Inspectors saw staff being kind and caring when they interacted with people.
“We observed staff interacting with people and found they were kind and caring.” from the report
Weak quality checks
needs fixingAudits had not always found problems or ensured that known issues were fixed promptly. A new auditing system was being introduced but was not yet embedded.
“Systems in place to monitor the service were not always effective.” from the report
Cleaning and maintenance
needs fixingInspectors found areas needing deep cleaning, untidy storerooms and items that needed cleaning or replacement. The manager took immediate action.
“Some food was left uncovered, a bath seat that required cleaning and a toilet seat which needed replacing.” from the report
Mealtime experience
needs fixingProblems already identified in a meal audit were still present nearly six weeks later. These included limited choices, no second helpings and unsuitable presentation of courses.
“All these issues were still apparent during our inspection almost six weeks later.” from the report
Personalised care details
minorSome personal items were not named, and some mealtime arrangements were not fully person centred. People living with dementia might have benefited from visual menu support.
“Hairbrushes and toiletries were found in communal bathrooms and storerooms with no names on” from the report
As-needed medicines guidance
minorInstructions for some medicines given when needed did not fully explain how people might show that they needed them.
“Protocols could be more informative about how people may present when they required their medicines.” from the report
- 01What changes have been made through the new auditing system, and how do you check that actions are completed promptly?
- 02Have all the cleaning, maintenance and food hygiene issues found at the inspection been resolved?
- 03What has changed in the meal choices, second-helping arrangements and presentation of meals since the inspection?
- 04How are personal items labelled and kept separate so they are returned to the right person?
- 05Has the manager completed registration with the CQC, and how is the home being overseen while this is completed?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from an earlier comprehensive inspection. This explanation was written from the published report of 18 May 2022 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 Castleford Lodge
5 rated inspections over 5 years: the service has improved, from Inadequate to Good.
- August 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2022Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021Goodstayed GoodSafe: GoodWell-led: Good
- June 2018Goodup from Requires improvementSafe: GoodResponsive: Requires improvementWell-led: Good
- June 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- October 2016
Registered with the Care Quality Commission on 5 October 2016.
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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