Castle Keep

Castle Keep is a residential care home providing personal and nursing care for up to 49 people across two designated wings; Nightingale for people living with dementia and Willow for people with complex health care needs. Each wing has a separate entrance and adapted facilities to suit the needs of the people living there. The service provides support to people living with dementia, older people, people with a physical disability and younger adults. At the time of our inspection there were 47 people using the service.

People’s experience of using this service and what we found

The service did not have a registered manager in place; however, a manager had been recruited and was waiting for their application to progress through the Care Quality Commission.

People received their medicines as prescribed. Medicines are stored correctly; staff keep accurate medicines records and manage medicines consistently and safely.

Effective safeguarding systems were in place. Safeguarding concerns were managed consistently and promptly. All staff had an awareness and understanding of abuse and felt comfortable raising concerns about their own or other people’s safety.

Risk assessments were person centred and contained enough information to guide staff in their practice. There was a culture of learning from accidents and incidents.

There was enough competent staff across the service to meet people’s needs. Recruitment processes were robust and appropriate recruitment checks were carried out. One relative told us “There is always enough staff around if you need them.”

Infection, prevention and control was managed well. Staff were trained and understood their responsibilities for maintaining high standards of cleanliness.

The service had a positive culture that is person centred. The provider, manager and staff had a good understanding of equality and diversity and this was promoted through the workforce. Relatives told us “The staff are brilliant; they go above and beyond” and “The staff are lovely and it is a lovely atmosphere.”

The manager had effective governance systems in place. Risks were identified through audits and action plans were produced that monitored the services performance and used the information to drive improvements through the service.

People and their families were involved in a meaningful way and their feedback used to drive improvements in the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at http//www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 30 March 2020). At our last inspection we recommended that the provider consider current guidance on administering and recording medicines and update their practice accordingly. At this inspection we found the provider had acted on the recommendations and had made improvements.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Castle Keep on our website at http://www.cqc.org.uk.

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Castle Keep is a residential care home providing personal and nursing care. The care home accommodates 61 people across two designated wings; Nightingale for people living with dementia and Willow for people with complex health care needs. Each wing has a separate entrance and adapted facilities to suit the needs of people living there. At the time of the inspection, there were 39 people living in the service.

People’s experience of using this service and what we found

Two people had not received their medicines as prescribed, as they were often asleep at the time nurses administered them. This needed to be checked out with the prescriber so the timings could be altered. There was also clearer guidance needed for staff when administering medicines ‘as and when needed’. We have made a recommendation about this aspect of medicines management.

There was no manager registered with the Care Quality Commission. An experienced manager from another unit had been supporting the service but, as they were leaving, an operations manager had been identified to take over the post. The operations manager will apply for registration with CQC and will oversee the service until a new manager is recruited.

There were some areas of the environment that needed attention in relation to unsafe furniture and cleaning routines. These were addressed on the day and the manager assured us a more robust checking system would take place. Other aspects of the provider’s quality monitoring were good. Following the inspection, we were told the refurbishment plan, which was already in place, would be adjusted to address the priority actions identified on the first day.

Staff were recruited safely and there was enough staff on duty. The manager told us when more people were admitted to the service, the staffing levels would be adjusted.

Staff knew how to safeguard people from the risk of abuse or harm.

Staff assessed people’s needs and identified risks so these could be minimised. Care plans provided guidance for staff in how to meet people’s needs in the way they preferred. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s health and nutritional needs were met. Staff ensured people had access to health care professionals when required. The menus provided choices and alternatives; those people at nutritional risk were monitored closely.

People’s privacy and dignity were respected. There were positive comments about the staff team and their approach when supporting people.

The provider had a complaints procedure and people felt able to raise concerns.

For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 26 July 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Castle Keep is registered to provide personal and nursing care for 61 people. Although the home is registered for 61 people it can only accommodate 49 people. We brought this to the attention of the registered manager who said they would discuss this with senior management and amend as necessary.

Castle Keep is a single storey, purpose built home. The home is divided into two parts, Willow and Nightingale; both support people with nursing care needs. Nightingale can support a maximum of 21 people who are living with complex dementia care needs. Both units have a selection of communal rooms and bathrooms. At the time of inspection there were 49 people living at the home.

We carried out an unannounced comprehensive inspection of this service on 16 December 2014 and gave an overall rating of Good. Since that inspection we received concerns in relation to people receiving the right amount of care. As a result we undertook a focused inspection on 17 March 2016 to look into those concerns. The safe domain was rated as requires improvement as there was a reliance on agency staff until recruitment had been completed.

During this inspection carried out in June 2017 we found improvements had been made. There was less reliance on agency staff, the home was fully staffed and there were appropriate numbers of suitably qualified staff on duty to meet people’s needs.

We received consistent positive feedback about the care provided at Castle Keep from people who lived at the home and their relatives. One relative told us, “It’s absolutely reassuring my [relative] is in a safe, warm place being looked after by caring, experienced staff.”

We observed staff providing support to people throughout our inspection visit. We saw they were kind and patient and showed affection towards people in their care. Staff were seen to maintain people's dignity throughout the day.

Staff had been recruited safely, received ongoing training relevant to their role and were supported by the registered manager. They had the skills, knowledge and experience required to support people in their care. People told us there was enough staff on duty and the staff came quickly to any requests for support.

Staff knew people they supported and provided a personalised service. Care plans were organised and had identified the care and support people required. Care records were informative about care people had received.

Risk assessments had been developed to minimise the potential risk of harm to people during the delivery of their care. These had been kept under review and were relevant to the care provided.

Systems were in place to reduce people being at risk of harm and potential abuse. Staff had received up to date safeguarding training and understood the provider's safeguarding adult’s procedures.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

We looked around the building and found it had been maintained, was clean, hygienic and a safe place for people to live. We found equipment had been serviced and maintained as required.

We found medication procedures at the home were safe. Staff responsible for the administration of medicines had received training to ensure they had the competency and skills required. Medicines were safely kept with appropriate arrangements for storing in place.

People who lived at the home told us the quality of the food was good. Records showed people were assessed to identify the risks associated with poor nutrition and hydration. Where risks had been identified, staff had made appropriate referrals to health care professionals.

The registered manager used a variety of methods to assess and monitor the quality of the service. These included regular audits and relative surveys to seek their views about the service provided.

The registered manager and staff told us they fully involved people and their families in their care planning. People were encouraged to raise any concerns or complaints. The service had a complaints procedure. People we spoke with said they felt comfortable raising concerns if they were unhappy about any aspect of their care.

The registered manager kept up to date with current good practice guidelines by attending a general managers meetings (organised by the provider Barchester Healthcare Homes Limited) at which they shared learning and discussed new developments in care. We found the registered manager receptive to feedback and keen to improve the service. The registered manager worked with us in a positive manner and provided all the information we requested.

We carried out an unannounced comprehensive inspection of this service on 16 December 2014 and gave an overall rating of Good. Since that inspection we received concerns in relation to people receiving the right amount of care. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Castle Keep on our website at www.cqc.org.uk

This focussed inspection took place on 17 March 2016 and was unannounced. On the day of the focussed inspection there were 27 people in Willow and 16 people in Nightingale.

This service is required to have a registered manager and there was one in post. 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 there had been times when there was a shortage of permanent staff on duty due to short notice absences. This had been filled with agency staff when possible although a small amount of shifts had been under the optimum levels of staffing numbers decided by the registered provider to meet people’s assessed needs. Staff had reported these shifts were difficult and tiring although people had remained safe and their basic needs had been met. There had been a reliance on agency staff until recruitment had been completed. The registered manager confirmed a full complement of permanent staff would be in place by 4 April 2016 and additional staff transferred to Castle Keep in May 2016.

We found more information could be obtained from agencies, to verify training, when staff supplied by them were used in the service.

People had a choice about the time they awoke in the morning and were not left waiting for long periods for support from staff with things such as their breakfast and their prescribed medicines.

We found people received appropriate pressure relief in line with their needs and action had been taken to treat two people’s long standing skin conditions. Records of wound management could be more consistent.

People’s nutritional and fluid intake was monitored when they were at risk and most people’s weight was stable. Appropriate referrals were made to health professionals such as GPs and dieticians when required so treatment could be prescribed.

We found there were two activity co-ordinators who organised a range of activities for people to participate in when they were able to.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with relatives and people who used the service and speaking with staff. We also looked at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that a lack of nursing oversight regarding the care people received had led to specific care not being provided to people. Risk assessments and care plans were not consistently updated and referrals to health professionals were not always completed in a timely way.

We found a third of staff had not completed training in safeguarding adults from abuse.

We found that medicines were managed safely, although there were some minor recording issues.

Improvements had been made to the environment. The issues with the heating system identified at the last inspection on 20 December 2014 had been addressed and the nurse call system upgraded.

We found there were sufficient members of staff to support people safely.

Is the service effective?

People's health and social care needs were assessed but we found care and treatment was not always planned and delivered in line with their individual care plan.

A health professional told us that over several months, the collaborative relationship the health professionals had with management and qualified nurses in Castle Keep changed and was not as good as it used to be.

We saw that not all nurses had received training in how to catheterise people. This was an important aspect of their skill requirement.

We observed good standards of personal care such as the way people were dressed.

We found the service provided nutritional meals with choices and alternatives. People liked the meals, especially the main meal of the day but said other courses could be improved and could be more in line with the needs of people with dementia.

Is the service caring?

People were supported by kind and attentive staff. We observed a member of staff support a person in a kind and gentle way which prompted a lovely smile from the person. We saw that staff showed encouragement and patience when supporting people. We observed staff using patience and skill to calm and comfort people who were anxious or upset.

People's preferences, likes and dislikes had been recorded and care and support was provided in accordance with people's wishes and choices. Staff demonstrated they knew people's preferences.

Is the service responsive?

We found that although people who used the service had access to health professionals, staff did not consistently respond to health care issues in a timely way.

Most people told us they felt able to complain and make suggestions about the service during meetings and on a day to day basis. One relative felt their complaint had not been dealt with to their satisfaction.

Is the service well-led?

There had been several changes in overall management and heads of unit for Nightingale and Willow over recent months, which had led to instability of the service. Because of the management changes there was evidence that learning from incidents had not taken place and appropriate changes were not implemented as swiftly as they should have been.

We found there was a lack of nursing oversight into the care some people who used the service required. The new manager had recently transferred from another location within the Castle's complex. They were aware that improvements were required and were confident these would be completed.

We asked staff if they felt supported by management. Comments included, 'Management is really good' and 'Very good support.' One member of staff told us that because of management changes over the last few months they hadn't felt supported. Another member of staff told us management support was getting better but because there had been so many changes care staff had not had time to get to know managers properly. Staff confirmed they had access to supervision meetings and used these to talk through concerns.

We found that although the service had a quality monitoring system it may not have been effective in the last several months as audits and evaluations of care plans had not been completed or acted upon. There had also been communication issues between staff managing the service and senior management.

We observed the new manager to be approachable and people who used the service and their relatives knew them.

What people who used the service and those that matter to them said about the care and support they received: -

One person told us they were happy at the home and pleased with the care they received. They said staff were helpful and nice. Comment included, 'There is always someone about to change music and have a chat with' and 'I have a shower and a wash when needed.'

People liked the meals provided and said, 'Meals are good, always a choice,' 'Very tasty and nice', 'Meals are fine ' all is ok there' and 'The staff always find me something I like.'

Relatives told us improvements could be made in communication, pressure relief and stability of management. One relative said, 'I have some concerns about liaison with and between nursing staff especially agency staff', 'I also have concerns about basic nursing issues', and 'I think Castle Keep is set in beautiful surroundings and has a lot to offer but needs a bit of tweaking.' Another visitor expressed concerns that nursing staff did not deal with health issues as quickly as they should and did not manage their relative's care needs effectively.

Other comments included, 'Yes he is always smart and well presented', 'I am pleased with the care', 'I've seen GPs come in, opticians and the falls team', 'She is happy here; staff do meet her health needs' and 'They always knock if the door is closed.'

One person's relative said the meals were very nice and their mother liked the food and had put on weight. Other comments included, 'The main meal is excellent but other courses could be improved', 'They do get a choice of food and there is a good breakfast', 'The meals look great and he eats very well', 'Recently there have been no menus on display and the menus can be a bit misleading regarding choice. I'm not sure some of the choices are suitable, especially the buffet meal on Sundays' and 'Sometimes the food isn't hot enough and the plates are cold.'

One visitor told us they found their relative's bedroom was personal, neat and tidy when they visited. They said their relative had new floor covering to meet a change in their needs. Comments included, 'The environment is as good as it can be' and 'It's clean and tidy.'

Comments about the staff team included, 'Day to day I witness kindness and caring; they get him to smile', 'The staff are excellent - very helpful', 'There are generally enough staff but occasional shortages leads to rushing' and 'She can still get agitated but the staff are really good at dealing with this.'

One relative told us staff worked in other units, which affected continuity. They felt this was not good for people with dementia. Another relative told us they felt there was not enough nursing staff and this had impacted on the care their relative had received.

One relative said, 'I think the home is well managed', whilst another relative said, 'I feel the frequent rotation of managers means they don't get a deep enough understanding of the clients.'

We found people's nutritional needs were met and menus provided a variety of food and alternatives. Comments from people who used the service included, 'Mostly I like the food but it can be variable' and 'Yes they will give me something different if I don't like it.'

We found people were protected from the risk of harm and abuse by staff adherence to policies and procedures, safeguarding training and staff guidance on behaviour management for people most at risk.

Although clean and tidy, we found some areas of the home were in need of redecoration and refurbishment. The heating system in one part of the home was not working effectively on the day of the visit.

People told us the staff team were kind and caring. We found there were enough skilled and experienced staff on duty each day to support people generally and with one to one care. We found the service was undergoing a management transition and once completed this should enhance the team structure.

There were systems in place to check the quality of the service and ensure people were able to express their views about the care and treatment they received.

People spoken with told us they were able to see their doctor or district nurse when required and their health care needs were met. Comments from people included, 'The doctor came last night as I wasn't well' and 'You are looked after really well.'

We found that staff had received training in how to safeguard people from abuse. People who used the service told us they felt safe in the home and they would tell people if they were worried about anything.

People spoken with told us they received their medicines on time and they were not kept waiting for important medicines such as pain relief. We found there were systems in place to manage medicines safely.

We found the service had a training plan and staff had access to a range of training which enabled them to meet people's needs.

People spoken with said they knew how to make a complaint and provided us with names of specific staff they would speak with if they had concerns. Comments included, 'I would see the nurse. Yes, I feel able to tell them when things are wrong.'