The inspection was carried out by one inspector. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;' 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.'