Castle House

We found the following examples of good practice.

The service had good clear signage at the entrance of the home explaining visiting arrangements, what to expect and a supply of personal protective equipment (PPE) for visitors to use.

Visitors were only permitted via prearrangement and were asked a health declaration and to take a lateral flow Covid test. Visitors were asked to wait in their car or entrance lobby for test results before being admitted.

Staff were ensuring people were being supported in their rooms as they had had some staff test positive. These staff were self-isolating, but as a precaution they were ensuring social distancing and isolating people in their rooms until whole home test results were back. Staff reported that this was a challenge due to people’s dementia needs, but they had managed this well.

There was a plentiful supply of PPE.

Regular testing was occurring, and a dedicated member of additional staff had been rotated on to ensure this ran smoothly.

Staff were working hard to ensure people had regular comfort visits in the rooms to check they were ok and to spend time with them as needed.

The laundry area was being refurbished to make it easier to ensure infection control processes were being followed.

The service had developed policies and plans to ensure any outbreak was being managed within the national guidance.

Staff were due to have updated training from the local CCG specialist infection control team.

Castle House is a residential care home providing personal care and support to 25 people aged 65 and over at the time of the inspection. The service can support up to 33 people.

Castle house is a large detached adapted house in the town of Torrington. It has bedrooms on two floors with access via a passenger lift and stair lift to some areas. The communal areas such as lounge and dining rooms are all on the ground floor

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

People said they felt safe and well cared for. People enjoyed living at Castle House. Most people were local to the area and enjoyed the fact they could still see friends and family and visit the market town they were familiar with. One person said “I wouldn’t want to live anywhere else. This is a lovely home and its near to my family.”

People were well cared for by a staff team who understood their needs, wishes and preferred routines. Staff were trained and supported to do their job safely and effectively. There were sufficient staff to meet people’s needs in a timely way. One person said, “We have been a bit short staffed, but no one has suffered. The staff work very hard and are really good.”

Medicines were being safely managed. People received their medicines as prescribed, but the recording of medicines administration was not always consistent. Following feedback, the registered manager addressed this quickly so recording was robust and in line with best practice.

People were protected from abuse because staff had training to understand who and when to report any concerns to. Robust recruitment processes ensured only staff who were suitable to work with people who may be vulnerable were employed.

People’s healthcare needs were being well met. The service worked in partnership with other healthcare professionals to achieve good outcomes for people. This included good food and fluid intake.People said they enjoyed the meals, drinks and snacks being offered. Mealtimes were relaxed and seen as a social occasion.

Staffing levels were sufficient to meet people’s needs. Improvements had been made to ensure people had activities in line with their wishes. This had included more opportunities to access the local community.

Care and support was being well planned and where possible people and their family were involved in the development and review of their care plans. Risks were being identified, assessed and monitored in line with best practice.

People, relative and staff views were asked for and acted upon.

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.

There were quality assurance processes in place to review and improve the care and support being delivered. This helped to ensure good outcomes for people.

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

Rating at last inspection the last rating for this service was good (last report published July 2017)

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.

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 and making improvements to medicine management.

There were some gaps in record keeping, but on most days staff had detailed what care and support had been delivered to each person.

On the day we inspected we found the kitchen was really hot and the staff in there needed some ventilation. There was an ineffective fly screen on the door and no fly screen on the window.

We identified one breach of regulation at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

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 how to report if concerns were raised. Measures to manage risk were as least restrictive as possible to protect people’s freedom. Medicines were not always safely managed on people’s behalf.

Care plans had been re written in a new format. They were personalised and recognised people’s social and psychological needs. However they still lacked detail regarding people’s health needs. People’s views and suggestions were taken into account to improve the service. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

The registered manager and staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA.

People were supported to eat and drink enough and maintained a balanced diet. The registered manager had been working closely with people and staff to provide a menu that all people at the service would be happy with. Staff relationships with people were strong, caring and supportive. Staff were motivated and inspired to offer care that was kind and compassionate.

Staff supported people to follow their interests and take part in social activities. A designated activity person was employed by the provider and supported people at the service to take part in activities.

The culture of the home was open, friendly and welcoming. The registered manager had developed clear leadership and was delegating staff roles and responsibilities. The provider had a range of quality monitoring systems in place which were used to continually review and improve the service. However they had not identified the areas we identified in relation to fire safety or medicines. Where there were concerns or complaints, these were investigated and positive action taken.

We identified three breaches of regulation at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

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.

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.

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.

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.