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Inspection carried out on 12 June 2017

During a routine inspection

This inspection was a comprehensive inspection and took place on 12 June 2017.

At the last comprehensive inspection, completed in March 2016, we rated the service as overall ‘requires improvement’. We issued requirements in relation to care planning, risk assessments and management of medicines. We also issued a warning notice in relation to the risk of fire safety.

We followed this up in a further focussed inspection completed in July 2016. We found fire risks were being monitored and the service had met the warning notice. We also found that although some improvements had been made in respect of medicine management, further improvements were still needed.

The registered manager sent us an action plan to show how they intended to meet regulations.

Castle House is registered to provide personal care for up to 33 people. They provide care and support for frail older people and those people living with dementia. On the day of the inspection there were 22 people living at the home, including one person who was having a short stay there (respite).

There was a registered manager who had been in post for 12 months. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found improvements had been made in the way care and support was being planned for people. This included ensuring any risks were understood, monitored and actions taken to mitigate any assessed risks. Care plans and daily records gave a good account of the needs and the support people had. It included what staff were doing to ensure people’s needs and wishes were being met.

There were improvements in medicines management, but records relating to these required further improvements. The service’s own audit had already picked up this issue. They had implemented further training and ‘spot checks’ for staff completing medicine rounds including the records. They had also been completing competency checks on staff skills in relation to medicines and had been proactive when they had identified issues in staff competencies.

There were sufficient staff with the right skills, knowledge and experience on duty to ensure people had effective care and support. People said staff were kind and caring. We observed staff providing support in a respectful and compassionate way. There were good relationships between staff and people who lived at the service. There was lots of laughter and good humour throughout the day.

Staff had the right support and training to do the job effectively. The staff team felt the views were valued and that the management approach was open and inclusive.

Staff understood how to protect people’s human rights, ensure any concerns were reported and that people felt safe.

There was a range of activities available for people to enjoy. This included occasional trips out into the local community. Those people who spent most of their time in their room were offered support to try new activities and to help ensure the prevention of loneliness and isolation.

People were offered a wide choice and variety of food. Menus were regularly discussed and amended to include people’s preferences. Where people were at risk of poor nutrition due to their health conditions, staff monitored their weight and their daily intake of food and fluid. People whose weight had decreased, were referred to their GP for advice and support with maintaining their weight through supplements.

The service had safe recruitments processes which ensured staff were only employed once their pre-employment checks had been completed. Staff knew how to report possible concerns about abuse.

Inspection carried out on 18 July 2016

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 24 March 2016. Breaches of legal requirements were found. We issued requirement notices and a warning notice in respect of these breaches. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the management of medicines, ensuring the environment was safe and updating care plans so people received safe and effective care.

After that inspection we received concerns in relation to poor moving and handling, poor medicine management, poor record keeping and lack of staff to provide safe and effective care. As a result we undertook a focused inspection to look into those concerns. We were also following up on the warning notice issued in respect of fire safety and risk assessments. This report only covers our findings in relation to those/this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Castle House on our website at www.cqc.org.uk

We completed this unannounced focussed inspection on 18 July 2016. Two inspectors completed the inspection.

Castle House is registered to provide personal care for up to 33 people. They provide care and support for frail older people and those people living with dementia. On the day of the inspection there were 17 people living at the home, including one person who was having a short break there.

Since the last inspection the registered manager had resigned and left the service. A new manager had started and been in post for fours day prior to our inspection visit. She has experience of being a registered manager in other services and will apply to register with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

In addition to having a new manager the service had employed a deputy manager to assist with the running of the service. They had just started their first day when the inspection visit occurred. The deputy manager also has experience and knowledge of running services. The manager and deputy had worked together previously and described themselves as ‘‘complimenting each other, having different skill sets but the same core values of wanting to provide the best quality care possible.’’

During this inspection we found the areas of concern around fire safety in relation to fire doors had been actioned. The service had also completed risk assessments for the use of portable radiators. We were satisfied the warning notice had been met.

The concerns identified to CQC in relation to being short staff was found to be an issue. The previous four weeks rotas showed staffing levels had fallen below what the provider had assessed as being needed. However the operations manager and manager of the service had been actively recruiting for new care staff. They had also been using agency staff to fill known gaps.

We found no evidence to substantiate poor moving and handling on the day of the inspection. Staff confirmed they had the right equipment and had received training to help them transfer people safely. On the day of the inspection, they were short by one care staff as one agency staff had not turned up. The length of time it took to get people into the dining room was over half an hour which delayed people having lunch at the time they would normally have it.

Medicine management still required some improvements. The deputy manager was starting the process of a complete medicine audit and had picked up on the same issues we identified during our inspection. They sent us an action plan following the inspection which detailed how they would be addressing issues identified an

Inspection carried out on 24 March 2016

During a routine inspection

This inspection took place on 24 and 31 March 2016 and was unannounced. Castle House is registered to provide personal care for up to 33 people. They provide care and support for frail older people and those people living with dementia. On the first day of our visit there were 16 people living at the service which included two people receiving respite support. On the second day of our visit another person had come to the home for a short stay, making 17 people at the service.

We carried out an unannounced comprehensive inspection of this service on 15 and 18 December 2014. Breaches of legal requirements were found. We returned on 30 April 2015 and undertook a focussed inspection to check whether requirements had been met. CQC took enforcement action because improvements were needed in relation to staffing arrangements and the Mental Capacity Act 2005. We therefore undertook a further focused inspection on 17 September 2015 to confirm that they now met legal requirements in relation to the warning notices. We found that although issues highlighted in the warning notices had been addressed, there were still areas of improvement needed. An issue was identified in respect of people not being protected against the risks associated with unsafe or unsuitable equipment. This was because there was no record of what staff should check to ensure the equipment was being used properly and it had not been regularly maintained. We found this had been addressed by this inspection.

In July 2015 the provider had made changes to their registration with the Care Quality Commission and had removed two regulated activities which meant they were no longer providing placements for people with on-going nursing needs. People living at Castle House were now under a residential service contract and any nursing needs were being met by the community nurse team. Care staff had received training to take over some roles previously completed by nurses.

The service had an advisory placement suspension in place with the local authority. This meant that all new admissions into the home had to be agreed by the local authority health and social care cluster manager on a case by case basis. The registered manager was also working with the local rapid intervention team and had been taking people who required respite support. They were also working with the local authority quality assurance and improvement team to develop and progress their improvement plan.

When we visited there was a registered manager in post. The registered manager had started working at the home in June 2015. They became registered with the Care Quality Commission (CQC) in January 2016. A registered manager is a person who has registered with CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was very visible at the service and undertook an active role. They were very committed to providing a good service for people in their care and demonstrated a strong supportive approach to staff. Since this inspection, the registered manager has left and the service is recruiting for a new registered manager.

The premises and equipment were not always managed to keep people safe. Fire checks had not identified blocked fire exits and fire doors which did not close fully.

People were supported by staff who had the required recruitment checks in place. Staff received an induction and were knowledgeable about the signs of abuse and how to report concerns. All care staff had undertaken or were enrolled on recognised national qualifications in health and social care. Staff had been developing skills and knowledge to meet people’s needs. There were adequate staffing levels to meet people’s needs.

People felt safe and staff had a good understanding of what constituted abuse and

Inspection carried out on 17 September 2015

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 15 and 18 December 2014. Breaches of legal requirements were found. We also undertook a focussed inspection on 30 April 2015 to check whether requirements had been met. Some areas of improvement were found but there was continued non-compliance in areas of safety and ensuring there were enough staff with the right skills and competencies. CQC took enforcement action because improvements were needed to ensure the well-being and safety of people living at the home.

After the focussed inspection in April 2015, the provider wrote to us to say what they would do to meet legal requirements in relation to improving their service. The provider had until 31 July 2015 to make improvements and become compliant.

We undertook this unannounced focused inspection on 17 September 2015, to check that they had followed their plan and to confirm that they now met legal requirements in relation to the warning notices. This report only covers our findings in relation to the warning notices. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk. The inspection team consisted of one inspector.

The purpose of this current inspection was to specifically look at how consent was being gained and recorded for care and treatment. For people who lacked capacity, we needed to assure ourselves, their best interests had been fully considered in the use of equipment which may restrict their movements. This included the use of bedrails and pressure mats which alerted staff when people got up and moved from their bed or chair. Previously staff had a limited understanding of how to ensure their practice was in line with the Mental Capacity Act 2005 (MCA) which protect people’s rights. We had also found in the previous inspections staff lacked the right skills to provide care and support safely and effectively. In this inspection we were checking staff had received training and their competencies were being monitored.

We found that although issues highlighted in the warning notices had been addressed, an issue was identified in respect of use of some equipment which could place people at risk. This related to the use of pressure relieving equipment to prevent people developing pressure sores. We found pressure relieving mattresses were not set at the right setting for people’s weight. We found there was no documentation to show staff what setting this equipment should be set at to ensure its effectiveness for the person. We also found some of this equipment had not been serviced for several years. We have issued a requirement in relation to this breach in people’s safety. We were assured by the manager and operations manager they would take immediate actions to address this.

Since the last inspection this service had removed two regulated activities which meant they were no longer providing placements for people with on-going nursing needs. People living at this service were now under a residential service contract and any nursing needs were being met by the community nurse team. This meant the service no longer employed nursing staff. Care staff had received training to take over some roles previously completed by nurses. This included medicines administration and review and development of care plans for people. Care staff had received a wide range of training to enable them to take on additional duties. This training included understanding the MCA and Deprivation of Liberty Safeguards (DoLS).

Staff confirmed this training had been useful and they had been provided with prompt cards to remind them to consider consent and capacity into their everyday practice. Our observations showed this was working to good effect. We saw staff checking with people before delivering care and support, ensuring consent had been gained. Where people lacked capacity the service had evidenced that best interest meetings had been held to consider a particular decision was in the best interest of the person.

During this inspection we heard how staff had received refresher training in safe moving and handling. This included a practical demonstration of using moving and handling equipment. Our observations showed staff on duty were comfortable and confident in using equipment to safely transfer people from their armchair to a wheelchair to have lunch. Staff reported they felt they were working better as a team, had a manager they could share their views with and took responsibility for ensuring safe practices were used at all times.

Since the last inspection the registered manager has resigned and de-registered with CQC. A new manager had been employed who was in the process of applying to register with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Inspection carried out on 30 April 2015

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 8 and 15 December 2014. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches relating to staffing and to equipment.

We undertook this focused inspection to check that they had followed their action plan and to confirm that they now met legal requirements. Since our last inspection we had also received some information of concern and used this inspection to follow up on these concerns. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Castle House on our website at www.cqc.org.uk

During this focussed inspection we found there were continued breaches in relation to the supply of the right equipment to ensure people were kept safe and that their privacy and dignity was upheld. For example although the registered provider had provided more moving and handling equipment, they had not ensured there were sufficient jugs within the home for people to have access to drinks at all times. They had not supplied any means of screening for two people who shared a room. This meant staff could not ensure people’s privacy and dignity at all times.

We found that one person’s fire door had been hanging off its hinges for a month. There was also outstanding electrical work needed to ensure the building was safe.

Although care staff levels had increased, we found staff did not always have the right skills to ensure people’s needs were being met safely. For example we found that staff had not received training in understanding the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and how they applied this in practice. Staff were unsure what actions they would take if they felt people were being unlawfully deprived of their freedom to keep them safe. There were further examples of where nursing staff had taken decisions about people who were placed within the home as a residential placement and therefore their nursing needs should have been met by the community nurse team. We saw examples of poor decisions being taken without the right risk assessments or follow up taking place. This included one person whom staff were using bedside rails without a risk assessment or best interest decisions being completed. The bedside rails had been put up without protectors which could have caused injury to the person.

The registered manager had given her notice as she said she was not being supported by the provider, who had suggested she cover four nursing shifts in one week, instead of using agency staff. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found three breaches of Regulations in the Health and Social care Act 2008 ( Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of the report.

Inspection carried out on 8 and 15 December 2014

During a routine inspection

This inspection took place on the 8 and 15 December 2014 and was unannounced. There were 19 people living at the service. When we last inspected in March 2014 we found improvements were needed in the way the provider ensured there were systems in place for quality assurance. We asked for and received an action plan, which outlined how the provider intended to improve their quality assurance and audit system. This included timescales saying when they intended to be fully compliant. During this inspection, there had been some improvements. The provider had used an external quality assurance company to complete audits in all aspects of health and safety, staffing, records and quality of care and support being provided. Audit information was made available, but improvements were still required in order to evidence what the provider was doing about the results of audits and recommendations.

Castle House is registered to provide nursing and personal care for up to 33 people. They provide care and support for frail older people and those people living with dementia.

The registered manager had de- registered on the day we inspected and a new manager who had been in post since July 2014 was in the process of applying to register with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not always safe as there were not always sufficient staff with the right skills and experience to meet their needs in a timely way. The service had struggled to recruit and retain qualified nurses and the new manager was covering more than one shift per week, which meant her time was being taken away from management tasks. The provider had not used a dependency tool to review the number of staff needed to meet people’s changing needs.

There was an activities coordinator, who worked three days per week. One the days she did not work, people were left for long periods with little or no social engagement. There were several people who called out or made noises which would indicate their distress or need to have social interaction. There were not always staff around to provide this emotional support. In the mornings staff were busy getting people up and assisting them with washing and dressing. This meant interactions from staff were sporadic and task centred, although staff showed empathy and respect to people in all their interactions.

Equipment was not always being stored appropriately which could have been a trip hazard and placed people at risk. There were two available hoists, although staff described one as ‘‘not fit for purpose’’ as the legs of it splayed which made it difficult to manoeuvre around furniture. A further hoist was made available by the second day of the inspection.

Staff were caring and compassionate towards people and were being given updated training to help them develop their skills. However further training was needed to help staff understand the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS).

The manager had been working hard to introduce a more comprehensive induction programme for new staff and to source further training for staff to update their skills in areas of health and safety. Staff understood people’s needs and care plan information was being updated to reflect changing needs.

This inspection took place on the 8 and 15 December 2014 and was unannounced. There were 19 people living at the service. When we last inspected in March 2014 we found improvements were needed in the way the provider ensured there were systems in place for quality assurance. We asked for and received an action plan, which outlined how the provider intended to improve their quality assurance and audit system. This included timescales saying when they intended to be fully compliant. During this inspection, there had been some improvements. The provider had used an external quality assurance company to complete audits in all aspects of health and safety, staffing, records and quality of care and support being provided. Audit information was made available, but improvements were still required in order to evidence what the provider was doing about the results of audits and recommendations.

Castle House is registered to provide nursing and personal care for up to 33 people. They provide care and support for frail older people and those people living with dementia.

The registered manager had de- registered on the day we inspected and a new manager who had been in post since July 2014 was in the process of applying to register with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not always safe as there were not always sufficient staff with the right skills and experience to meet their needs in a timely way. The service had struggled to recruit and retain qualified nurses and the new manager was covering more than one shift per week, which meant her time was being taken away from management tasks. The provider had not used a dependency tool to review the number of staff needed to meet people’s changing needs.

There was an activities coordinator, who worked three days per week. On the days she did not work, people were left for long periods with little or no social engagement. There were several people who called out or made noises which would indicate their distress or need to have social interaction. There were not always staff around to provide this emotional support. In the mornings staff were busy getting people up and assisting them with washing and dressing. This meant interactions from staff were sporadic and task centred, although staff showed empathy and respect to people in all their interactions.

Equipment was not always being stored appropriately which could have been a trip hazard and placed people at risk. There were two available hoists, although staff described one as ‘‘not fit for purpose’’ as the legs of it splayed which made it difficult to manoeuvre around furniture. A further hoist was made available by the second day of the inspection. The provider had refurbished one of the bathrooms, but the bath installed was not appropriate for people with mobility or frailty issues. This meant people could only use the shower room.

Staff were caring and compassionate towards people and were being given updated training to help them develop their skills. However further training was needed to help staff understand the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS).

The service was not always being well-wed. the registered provider was in the process of recruiting a operations manager to support the manager of the homes they owned, but there was no interim arrangements. The registered provider had used an external quality assurance consultancy who had identified areas for improvement. The registered provider had not acted swiftly to address some of the areas for improvement, such as ensuring electrical equipment was tested for it’s safety.

The manager had been working hard to introduce a more comprehensive induction programme for new staff and to source further training for staff to update their skills in areas of health and safety. Staff understood people’s needs and care plan information was being updated to reflect changing needs.

People’s medicines were being managed appropriately and their health care needs were monitored. Where health care specialist advice was sought, their recommendations were put into action. People were afforded choice and where they were able to make informed decisions about their lives, staff respected this.

People and their families were able to talk to staff and the manager about any concerns they had and were mostly confident these would be dealt with. Two people did mention their concerns had not been dealt with to their satisfaction. The manager agreed to discuss their issues further with them.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 4 March 2014

During an inspection to make sure that the improvements required had been made

This was the third responsive inspection to follow up on outstanding compliance actions. We inspected this service 26 June 2013 following recept of information of concern. This indicated care and support to people may not have been safe, due to lack of staff, medication errors and security of the building. We set compliance actions in four areas as a result of this inspection. We asked for, and received an action plan, which showed how the service intended to be fully compliant. We completed further inspections in November and February to check on aspects of compliance. We also met with the provider to discuss their action plan, and talk about how CQC worked with providers to ensure compliance was achieved. This inspection was to look at the remaining outstanding compliance actions in care and welfare, staffing and quality assurance.

We spent time talking with people who lived at the home. Most people were unable to give an informed view, so we spent time observing how care and support was being delivered. We also spoke with three visiting relatives. We looked at four care plans and daily records in detail and spoke with nine staff about their understanding of peoples needs and wishes. Prior to the inspection we had received two pieces of concerning information relating to staff not understanding people's needs, and staffing levels.

We looked at staffing rotas and quality audits and checklists to help us understand how well the home was being run.

At the time of this inspection there were 20 people living at the home. There have been no new admissions since our June 2013 inspection. We found there had been improvements in the way care and support was being planned and risk assessments were being considered and updated in line with changing needs.

We saw new staff had been employed to deliver care and treatment. Staff told us they had been given an induction programme and were being trained to do their job effectively. Most of the shifts were covered with enough qualified and competent staff. There were two weeks where nursing shifts had been covered by the registered manager as two nurses had left. Some shifts had been covered by agency nurses but on five days of each week, the manager had been asked to cover nursing shifts, which meant she was not available to provide management cover for most of those two weeks.

We saw improvements had been made in the way the provider and manager completed checks and audits to ensure the home was safe and care plans and risk assessments were being monitored. We saw however, where areas of improvement had been identified in relation to the environment, the provider had been slow to act This meant people were subject to possible risks from an unsafe environment.

Inspection carried out on 4 February 2014

During an inspection to make sure that the improvements required had been made

We found that there have been improvements in the way medicines were managed. We saw that medicines were stored safely, and that recording of medicines has improved. We found that people were given their medicines safely and correctly.

Inspection carried out on 12 November 2013

During an inspection to make sure that the improvements required had been made

This follow up inspection was completed to look at four outcome areas where we had previously asked for improvements. We had received an action plan from the provider stating some of their improvements should have been completed by the end of October 2013. The provider stated they needed longer to recruit more staff and for the revision and updating of care plans, which would be completed by 15th December 2013. This home has been subject to safeguarding processes. Due to a number of alerts being made in respect of people's needs not being met, medication errors and staff shortages, CQC wanted to check people were safe and receiving the right care.

During this inspection we looked at four care plans in detail. We spoke with six staff members and we observed care and support for a short period prior to and during lunch being served. We reviewed their medication records, watched how medications were being administered during the lunchtime period and checked the stock within the home. We also looked at how the manager had been reviewing and monitoring medication practice.

We saw fire exits were now all alarmed so people would not be able to leave the building without staff being made aware. New glass had been ordered for the respite bedroom, but this was not being used. The staff toilet was not in use as this was being turned into a wet room.

We found improvements were still needed in staffing levels, managements of medications and in quality monitoring systems.

Inspection carried out on 26 June 2013

During a routine inspection

We carried out this responsive inspection as we had received some information of concern from more than one anonymous source. They had identified issues of security of the building, poor care practices in moving and handling and medication errors. All of these issues could have placed people at risk, so we visited to check people were safe and that their care needs were being met by competent and qualified staff.

We had previously inspected this service on 8 May 2013. Although we found the five outcomes we inspected to be compliant we highlighted staff concerns about the management style and approach of the registered manager and the provider. We heard the manager had enrolled on a manager's course to assist her in developing skills in effective management.

During this inspection, we looked closely at the care records and daily notes of four people, we spoke to six people living at the home and to six staff. We looked at all areas of the home including every bedroom. On the day of the inspection the lift was out of order, from the previous day.

We found there had been some serious errors in the management of medications for people. We have asked the service to make some improvements to ensure practice is more robust and fully protects people. We found some areas of the building needed improvements to meet standards and staffing levels needed to be considered to ensure a good skill mix were available for each shift.

Inspection carried out on 8 May 2013

During a routine inspection

We carried out this unannounced inspection over six hours and spoke with eight people who lived at the home and two visiting relatives. At the time of the inspection there were 24 people living at the home. We also spoke with nine staff including the registered manager. We looked at some key records, these included care plans, risk assessments, staff training and complaints. This helped us to make a judgement about how well the home was being run.

We found that people’s care was being well planned. People were involved in making decisions about their care and treatment. People we spoke with said they were happy with their care and support. Comments included ‘’I think we are well looked after. Staff try very hard and it isn't easy there are some people (who live) here who really try their patience.'' Another person told us ''All good, no complaints.'' We also spoke with a relative of someone who had fairly recently moved to the home. They told us ''X has settled very well, I am very pleased, the staff are all lovely, food seems really nice and everyone is kept nice and clean, they are very well looked after.''

Staff had training to do their job safely and effectively, but did not always feel well supported.

The service had systems in place to ensure people were encouraged to have their say and air their views about the service. People’s concerns were dealt with appropriately.

Inspection carried out on 2 May 2012

During an inspection to make sure that the improvements required had been made

We completed an inspection on 15 November 2011, to check on compliance actions set in outcomes 4,11,13,14, and 16. At that inspection we raised some concerns about equipment and found that staffing levels were not sufficient to meet the needs of people in a timely fashion. This placed people and staff at risk.

Following the inspection we asked for an action plan and met with the registered providers on 30 January 2012 to discuss how they intended to ensure their action plan was completed and compliance was achieved. We were assured that the issues identified in November 2011 had been addressed.

We carried out this unannounced inspection on 02 May 2012 as part of our planned inspection programme. We also wanted to check on the progress they had made in achieving compliance in relation to ensuring that equipment was in place and that staffing levels were sufficient to meet people’s needs.

We spent time at the home talking with five people who currently live there as well as with seven members of staff. We also observed how care and support was delivered through different times of the day. Most people that live at this service have dementia and therefore not everyone was able to tell us about their experiences. To help us understand the experiences of people we used our SOFI (Short Observational Framework for Inspection) This tool allows us to spent time watching what is going on in a service and helps us record how people spend their time, the type of support they get and whether they have positive experiences. Some people using the service were able to tell us their views. We also spoke with one visiting relative and one health care professional.

We looked at some of the key records kept by the home. These included care plans, risk assessments and staff training records. This helps us to better understand how well the home is run. Following the inspection we asked the manager to send us some additional information in respect of how they monitor and review the quality of care and support provided.

People we spoke with who were able to share their experiences of living at the service were positive. Comments included ‘‘everything is fine, I have no complaints’’ and ‘‘you can see we are well looked after, the girls are lovely here.’’

We heard that new staff had been employed, including an activities coordinator, new cook and more care staff. People confirmed that there had been more stimulation and that the menus were to their liking. No one we spoke with felt in their view that there had been too few staff on duty but one person did comment that there had been staff sickness. The manager confirmed that they had increased the staffing levels but that sickness had sometimes meant that shifts were one care staff short. We were told that the provider had agreed to employ agency care workers but these were not easy to find at short notice. At the time of this inspection there were 24 people living at the home with five care staff and one nurse for the morning shift and four care staff and one nurse for the afternoon shift.

We looked at how well care and support was planned and reviewed. The plans contained good basic information about what personal, health and emotional care needs people had and how staff should meet these needs. Risk assessments were in place to show how the home identified managed and minimised any risks for people.

We observed staff providing care and support in a kind and sensitive manner and we were told by staff that they felt that training was in place to help them do their job and support was now better.

We observed people experiencing positive interactions with staff trying hard to engage people. There were systems in place that ensured people’s views were listened to and acted upon.

Inspection carried out on 15 November 2011

During an inspection to make sure that the improvements required had been made

We carried out a responsive review on 3 August 2011 to check on compliance actions set from the planned review in February 2011. We were also responding to some information of concern about equipment within the home needing to be replaced and low staffing levels.

In August we set compliance actions in all six outcome groups we looked at. These included care and welfare of people, safeguarding, safety and suitability of equipment, staffing levels, training and support and records.

We completed a further inspection on 15 November 2011, to check on compliance of these outcome groups, but also in response to some information of concern around equipment not being replaced promptly, and staffing levels not being sufficient to meet the needs of people living at the home.

During this inspection we spoke with seven people living at the home and three visiting relatives. We also spoke with five members of staff including the new manager, one nurse, two care staff and the cook. We spent time observing care and had lunch with people at the home. We looked at some key records within the home. These included care plans, medication records, maintenance records and staff rotas

People we spoke to said that they were ‘‘well looked after’’ ‘‘Staff are very nice but very busy’’ and ‘‘I have settled well here they are all very nice.’’

We saw that care staff were very busy during the morning getting people up. There were several periods throughout the morning where there was very little contact with staff other than bringing more people down into the lounge once they had assisted them to get up and dressed. At one point there were four people sitting in wheelchairs who waited at least 30 minutes before staff were available to assist them into arm chairs. We observed staff being very courteous and caring to people, but they had very little time to interact with people other than to perform tasks such as moving and handling or offering a drink.

We observed one person being assisted to transfer from their chair to a wheelchair to go into the lounge with a handling belt. We checked their care plan and this showed that they should have been moved using a hoist. We asked staff why they had not used a hoist and was told that the hoist was being used to get the last people up from upstairs bedrooms, so they did not have access to it. This meant that this person was not moved in the correct way.

We were told that a new cooker had been installed on the day we visited. We were told that they had management to ensure that hot food was available throughout the short period they were without a cooker. The cook showed us menu plans and people we spoke with told us they were happy with the menu choices that were provided.

We looked at care plans and saw that these gave good details of peoples’ health and personal care needs. We saw that daily records monitored peoples’ health and emotional well being. We sat in on the staff handover, where the morning shift nurse went through peoples needs and how they had been during the morning shift. We heard that staff had good knowledge and understanding of peoples needs, and explained how needs had been met for people.

We will meet with the provider to discuss their action plan in relation to this review.

Inspection carried out on 3 August 2011

During an inspection in response to concerns

We carried out a planned unannounced inspection in February 2011 at Castle House. We looked at sixteen essential standards and we found that they were compliant in fourteen of these outcome groups. We made one compliance action relating to records for the home to complete in order to achieve compliance with the Health and Social Care Act 2008, and one improvement action relating to support for staff.

We carried out this responsive unannounced review on 3 August 2011 to check on the improvement and compliance actions that we had made after the previous inspection. We had also been informed of a concern relating to staffing levels at the home. We looked at six outcome groups during our inspection; health and welfare needs, safeguarding, staffing levels, support for staff, maintenance of equipment and records.

Our visit took place over six hours. When we visited the home, 21 people were living at the home and there was also one person on a respite stay. We spoke with eight people living at the home, seven staff members and four people visiting the home.

We met with people either in their rooms or in communal areas, and we spoke to them individually or in pairs when they were sitting with friends. We spent time in communal areas, which enabled us to observe people’s interaction with staff, and hear conversations between staff and people living at the home.

We used pathway tracking to see how two people’s care and social needs were met. We looked at their care records and spoke to staff about how they met their care needs. We spoke to staff about the management of staff supervision, induction and staffing levels. We talked to staff about the equipment they used and whether it supported them to do their jobs. As a result of our visit, we have contacted the Fire Service and Environmental Health about our concerns regarding staffing numbers at night and the performance of the home’s cooker.

We were told that there was nobody living at the home with a pressure sore, no one receiving end of life care, and no one with complex care needs either relating to physical or mental health needs.

The home does not currently have a registered manager but a new manager was appointed on 25 July 2011, and they told us that they had begun the first stages of the application to become registered.

We met people who looked well cared for. A visitor told us that their relative always had clean nails and hair. They were positive about the attentiveness of staff to ensure their relative had their audiology needs met, and we saw further examples of this during our visit.

People appeared relaxed in their surroundings and with each other. Some people enjoyed a joke with staff, and during a staff handover we heard examples of how staff recognised people’s individuality and heard about the different approaches that were adopted to suit people’s individual needs and character.

Seven people told us that they were satisfied with the standard of care provided at the home, and one person said they wouldn’t remain living at the home if they had any concerns.

We asked people how they spent their time. Seven people were unable to give us specific examples of events or activities that took place.

We asked people who they would go to if they had a concern about their care, and they told us they would speak to a staff member but generally they did not name a specific staff member.

We spoke to a person living at the home and they told us that sometimes there was a delay in them receiving help as the equipment they needed to use was on a different floor of the home.

We asked seven people living at the home about the quality of the food that was provided, including cooked meals. This was because we had been told that the cooker needed regular repairs to it. People were positive about the standard of the food, making comments such as the “food is wonderful” and “the cook is so kind”. They told us the food was well presented, with good choices and portion sizes.

We met seven people living at the home and they told us that they did not need to wait long for help, apart from one person (see outcome 11). In their opinion, there were enough staff and certainly we heard that staff were attentive, for example during meals, but there was little time for any meaningful conversation.

We did not ask people living at the home direct questions about staff training but in our general conversations with people about their experiences, they told us that staff knew how to care for them. One visitor told us that the staff were caring and described one staff member as being particularly thoughtful in the way they cared for people, which the person they were visiting agreed with.

Inspection carried out on 12 January and 15 November 2011

During a routine inspection

We spoke to nine people who live at the home and observed how people were being cared for over a period of two hours during the visit. Some people were more able to express their views and their experience at Castle House, others could not. People told us

‘’I like living here.’’

‘’Yes staff are nice, they take good care of us.’’

‘’Food is excellent’’

‘‘I have no complaints.’’

We observed people being given time to make choices and staff explaining what they were doing to assist people in their activities of daily living. We saw that people were comfortable and appeared settled in their environment, those who were able moved freely around the home. Individuals had personalised their rooms and we were told ‘’I spend most of my time here in my room, I love the view, staff help me to be as comfortable as possible and I am quite happy here.’’

‘’ I have a lovely room, I would like to be able to do more for myself and Jo the manager is looking into getting me an electric wheelchair which will really help me’’

We spoke to three nurses, three carers, the cook, the administrator and the manager. All said they enjoyed working at Castle House and were able to demonstrate good knowledge of the people who they support. Individuals who live at the home all spoke highly of the staff and said that they were treated with respect and dignity and that their privacy was upheld.

We saw that meals were attractively presented and people who needed help and support to eat were given this in a kind and caring manner. People expressed a high level of satisfaction in general with the standard, choice and variety of food offered. One person did comment

‘’You can tell if one cook is off, we miss their meals but overall the food is really very good.’’

We spoke to one visiting relative who confirmed that they could visit when they liked, and that they were made welcome.

We saw that although the building is old and some areas were a little shabby, that the environment had been made safe and comfortable for people. There was sufficient specialist equipment to ensure that the needs of people could be safety met, and we observed staff using this equipment in a confident manner.

Reports under our old system of regulation (including those from before CQC was created)