Castle Brook

Castle Brook is a care home. The maximum number of people the home can accommodate is 86. The service is delivered over three floors, which are subdivided into six individual households for up to 14 people. One household is a 're-enablement' unit for people who have been discharged from hospital but need further therapeutic input to build up their strength and mobility. Each household has their own communal lounge, kitchen and dining areas and people have access to the shared facilities in communal areas throughout the home. There were 82 people living at the home at the time of our inspection visit, some of whom were living with dementia.

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

There were enough staff to ensure people's needs were met in a timely way and staff were available in communal areas, should any assistance be needed. There were systems to assess, monitor and mitigate the risks relating to the health and welfare of people who used the service. Staff had completed safeguarding training and were knowledgeable about their roles and responsibilities in keeping people safe from harm, neglect and discrimination. Staff followed good hygiene practices and the home was visibly clean and there were no unpleasant odours. The electronic medication administration record (EMAR) did not always accord with medicines in stock which meant we could not always be assured people had received their medicines as prescribed. Systems were not robust enough to demonstrate medicine was effectively managed.

People’s needs and choices were assessed before they moved to the home and their care was delivered in accordance with current legislation and guidance. New staff members were provided with effective support when they first started work at Castle Brook and a programme of regular training updates supported staff to keep their skills and knowledge up to date. Staff worked in partnership with a multi-disciplinary team to enable people to live healthier lives, re-habilitate after a stay in hospital or manage long term medical conditions. People were supported to eat and drink enough to maintain a healthy diet. 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.

Managers and staff worked in accordance with the provider’s approach to care which was to make ‘Every Day Well Lived’. People and their relatives continued to be happy with the caring attitude of staff and the friendly and welcoming atmosphere within the home. Staff and managers understood the importance of promoting equality and human rights as part of a caring approach.

Care records contained enough detail to support staff to deliver person centred care in accordance with people's preferences and wishes. Person centred activities that encouraged physical, mental and social stimulation were an important aspect of the care provided at Castle Brook. End of life care plans were in place for those people who wished to engage with staff regarding end of life care planning. The provider supported people to spend their final days with dignity and pain free.

Since our last inspection the provider had worked with people and staff to ensure their values were understood and people had positive outcomes. People and staff were positive about a more cohesive and responsive management team who were more visible and spent time listening to people and staff. The provider worked in partnership with other organisations to support care provision and service development.

For more details 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 Requires Improvement (published 9 January 2019).

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 reinspection programme. If we receive any concerning information we may inspect sooner.

Castle Brook is a care home. People in care homes receive accommodation, and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The maximum number of people the home can accommodate is 86. The service was delivered over three floors, which were subdivided into six individual households for up to 14 people. One household is a ‘re-enablement’ unit for people who have been discharged from hospital but need further therapeutic input to build up their strength and mobility. Each household had their own communal lounge, kitchen and dining areas and people had access to the shared facilities in communal areas throughout the home. There were 55 people living at the home at the time of our inspection visit, some of whom were living with dementia.

At our last inspection in September 2017, the home was rated as ‘Requires Improvement’ in the key questions of 'safe,' ‘effective’ ‘caring’ ‘responsive’ and 'well-led'. There were five breaches of the Regulations. After that inspection the provider provided us with an action plan. This showed what they would do and by when, to improve all areas of the service we had concerns with to at least 'good'.

During this visit the provider had made a promising start to improving the service and the home was no longer in breach of the regulations, and had improved their rating to good in the three key areas of ‘safe’, ‘caring’ and ‘responsive’. However, we found further requirements were still required in ‘effective’ and ‘well-led’. The rating therefore remains ‘Requires Improvement’ overall.

Following our visit in September 2017 the provider put a management ‘task force’ into the home to understand the issues, develop staff and look at the systems and processes to support good service delivery.

In April 2018 they appointed a new manager who has subsequently become registered with us. 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. The new registered manager had a track record of managing an outstanding service and consistently demonstrated the provider’s values.

Staff and relatives told us the improvements instigated by the provider and new registered manager had resulted in improvements in the home and the culture of the service. However, because it had only been six months since the appointment of the new registered manager, there had not been sufficient time to be sure the improvements were embedded into every day practice and would be sustained. The registered manager and other members of the provider’s senior management team acknowledged that improvements were required to be sustained over a period once further people were admitted to the home.

People’s care plans identified whether they had the capacity to consent to living at the home. Where people required restrictions on their liberty to keep them safe from harm, Deprivation of Liberty Safeguards had been applied for. However, the provider was not always acting in accordance with their responsibility to provide care in the least restrictive way possible.

The provider had recruited more permanent staff and the staffing rota was now organised around individual households, to ensure people were supported by a consistent team of staff. Although there was still a high use of agency staff, the registered manager had made improvements to how staff were managed with more clarity about individual responsibilities. Staff said they now worked on the same household regularly, which meant they knew people well and could build effective relationships with them. Staff told us the supervision and appraisal process had improved, which gave them a renewed confidence in their abilities and the encouragement to continue to develop their skills.

Communication between staff and the registered manager, and between relatives and the registered manager, had improved. People, relatives and staff were now more confident issues raised would be taken seriously and action taken to improve the service provided.

The management of medicines in the home had improved. There were robust processes in place for the prescribing, ordering, checking, storing and disposal of medicines. Staff told us improvements in medicines management gave them more confidence people received their medicines safely.

People’s individual risks were assessed and their care plans were written to minimise the identified risks. Staff followed people’s care plans to keep people safe.

Staff understood their duty of care to keep people safe and report any concerns they had that people were at risk of potential or actual abuse, neglect or discrimination. The registered manager followed the local procedure for referring people at risk to the safeguarding authority.

People’s care plans included their medical history, which ensured staff understood risks to their health and the signs of ill-health. Records showed people were referred to other health professionals when a need was identified. People were encouraged to eat and drink enough to maintain their health.

Staff demonstrated an enthusiasm for providing a warm, friendly environment where people were made to feel they mattered. Staff’s behaviour and approach was in keeping with the provider’s aim, to ensure, ‘Every day is well-lived’. People were encouraged to maintain their interests, socialise and to create their own activity spontaneously.

People’s care plans included personal information, which recorded what was important to the person and how they preferred their care and support to be provided. Staff shared information at a handover between shifts so they could respond to people’s changing needs or abilities.

The provider had a system of checks and audits to identify where improvements were needed. Audits had led to actions which had improved people’s health and well-being. However, the audits had not identified the provider was not working within the principles of the Mental Capacity Act 2005.

The registered manager was committed to building on the improvements made in the last six months to ensure people received a standard of care that supported them to live a fulfilling and meaningful life.

The registered manager and provider understood their legal responsibilities to inform us of significant events that occurred in the service and to display the ratings from our last inspection visit.

There were two registered managers for this service. 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.

One registered manager had been appointed when the service was first registered in December 2016. They no longer worked at the home on a day-to-day basis, but retained managerial oversight of this and one other service in the provider’s group.

The second registered manager had transferred from another home in the provider’s group and had registered at this service in May 2017. When our inspection started, the second registered manager was responsible for the day-to-day management of the service and for the direct supervision and management of staff. We have referred to the second registered manager who had day-to-day responsibility for the service as ‘the home registered manager’ throughout this report.

During the course of our inspection, the home registered manager stopped working for the provider and an acting manager was appointed to take responsibility for the day-to-day management of the service. The provider has notified us of these changes in how the home was managed.

The service was delivered over three floors, which were subdivided into six individual households for up to 14 people. Each household had their own communal lounge, kitchen and dining areas and people had access to the shared facilities in communal areas throughout the home.

Medicines were not administered or managed safely. The home registered manager had not followed the provider’s guidance for managing and administering medicines safely in accordance with best practice. During our inspection visit, the provider took immediate action to improve how medicines were managed and administered.

Staff understood their responsibilities to protect people from the risk of abuse, but the home registered manager did not demonstrate understanding of their responsibilities. They had not always referred people to the local safeguarding agency promptly or notified us when they made a referral. The acting manager told us they would ensure statutory notifications were sent to us when required in future.

There were not enough, consistent oversight of agency staff’s practice to ensure their skills, experience and behaviour was of the same standard as permanent staff.

Staff were not consistently supported or supervised by senior staff they trusted and respected. Staff had not had the opportunity to reflect on their practice or consider their career development.

Improvements were required in identifying, responding to and analysing complaints.

The provider’s quality assurance process had not identified the extent of poor management of the service or the impact it had on people’s perception and experience of the service. When the provider was made aware of concerns about how the service managed, they took immediate action to investigate and improve the quality of the service.

Risks to people’s individual health and wellbeing were identified and care was planned to minimise the risk. People, relatives and staff felt the low number of permanent, sufficiently skilled staff was a risk to delivering safe care and support.

The premises and equipment were regularly checked to ensure they were safe for people to use.

The provider checked staff’s suitability for their role before they started working at the home. During our inspection, they took immediate action to make sure all agency staff were also suitable and appropriately skilled to deliver safe care and support.

Records showed the home registered manager understood their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. They had applied to the supervisory body for the authority to restrict people’s liberty to keep them safe. Staff understood their responsibilities in relation to the Act and checked that people consented to be cared for and supported.

People were supported to eat and drink enough to maintain a balanced diet that met their individual dietary needs and preferences. People were referred to healthcare services when their health needs changed.

Staff were caring and compassionate, but there were not always enough regular, known staff on duty to make people feel consistently valued. Staff told us they had not felt cared for or supported until the provider had appointed an acting manager.

People were supported to maintain their preferred and familiar routines and habits, but clubs, planned entertainments and events were not always held where people felt comfortable to attend them.

People, relatives and staff told us the service was not consistently well-led. The home registered manager was not proactive at obtaining feedback about people’s experience of the service.

Communication between staff and the home registered manager, and between relatives and the home registered manager, was not effective. People, relatives and staff were not confident that issues raised were taken seriously and were not advised how they would be resolved. The acting manager took immediate action to improve communication across the whole home and between all the individuals who had an interest in how the home was managed.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.