We carried out this unannounced inspection on 31October and 2 November 2017. At the last inspection, in August 2015, the service was rated Good. Castle Hill House is a ‘care home’ that provides nursing care for a maximum of 43 older people who have nursing and or mental health needs. The service was divided into two areas, the nursing floor and the residential floor. At the time of the inspection there were 33 people living at the service. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
There was a registered manager in post who was responsible for the day-to-day running of the 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 and associated Regulations about how the service is run.
At this inspection we found some people did not receive their care in a timely manner. On the day of the inspection there was one less member of staff on duty on the nursing floor, this was due to sickness. On the residential floor there were 10 people who needed two staff to support them to get up and to provide personal care. As there was only one team, consisting of two staff, some people were not helped to get up and dressed until 11.45 am. We also found that call bells were not always promptly answered, in four observed incidents, taking between 10-15 minutes to respond to people’s needs. People told us they didn’t mind waiting for assistance from staff. One person said, “Staff are very good. I don’t mind waiting, I am not going anywhere.” Staff prioritised who they helped, regularly checking if people needed anything, and keeping people informed of any delays. However, there were not enough staff on duty to ensure people could receive their care when they needed it.
We had concerns about inconsistent and missing records in relation to medicines administration, assessments of people’s mental capacity and some people’s care records. There were gaps in Medicine Administration Records (MARS). Topical creams had not been dated on opening and there were missing records of when creams were used. There were discrepancies between records of medicines given and the stock held for some people. The temperature of the medicines room was too high and there were some out of date swabs, specimen and blood bottles held by the service.
Management and staff had some understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Applications for DoLS authorisations had been made to the local authority appropriately. There were instances where staff had sought advice from external professionals to assist them in assessing the person’s capacity. There was evidence of where best interest meetings had taken place, with families and healthcare professionals, when decisions needed to be made on a person’s behalf. However, the service had not carried out their own assessments of people’s mental capacity and decision making ability in line with the legal requirements of the MCA. This meant there was no written guidance for staff about how to support people to make their own decisions.
When people had specific health needs advice and guidance was sought from healthcare professionals. However, when advice was given by professionals, staff were not always provided with written instructions to enable them to consistently follow the guidance. Where people were assessed as being at risk of losing weight their food and fluid intake was monitored. When records indicated that people had eaten or drunk less than their assessed level it was not clear if any action had been taken to ensure people were hydrated and nourished. Where people had been assessed as being at risk of losing weight their weight was not regularly checked. When people’s weight was checked records did not show if any action had not been taken when weight loss was noted.
There were assessing and monitoring systems in place and audits of all aspects of the service were carried out. However, when audits identified areas for improvement there was no clear action plan put in place, with a timescale, of when the improvements would be carried out. For example, some of the areas for improvement we found at this inspection had been identified through the service’s own auditing system but action had not been taken to make the necessary improvements.
People received care and support that was responsive to their needs because staff were aware of the needs of people who lived at Castle Hill House. Any risks in relation to people’s care and support were identified and mostly appropriately managed. Some people’s care plans had not been updated to reflect the care they received. We have made a recommendation about care plans.
People, and their relatives, told us they were happy with the care they received and believed it was a safe environment. Comments included, "I feel safe because when I was ill a staff member stayed with me", "There is always someone around if you need help", "I feel safe because of their kindness", "If I want anything, I only have to say” and "I know my relative feels safe because they are not in any pain or discomfort."
On the day of the inspection there was a calm, relaxed and friendly atmosphere in the service. We observed that staff interacted with people in a caring and compassionate manner. People told us staff were kind to them and respected their wishes. Comments from people and relatives included, "They are like a family to me", "One of the staff goes out shopping with me", "They show me lots of respect", “My relative likes to think of her carers as friends”, “All the staff are so friendly" and "The staff are always popping in to see mum."
Staff were supported by a system of induction training, one-to-one supervision and appraisals. People were supported by staff who knew how to recognise abuse and how to respond to concerns. Staff received training relevant for their role and there were good opportunities for on-going training and support and development.
People were able to take part in a range of group and individual activities. A full time activity coordinator was in post who arranged regular events for people. These included board games, jigsaws, baking, craft work, and bingo as well as external entertainers and religious services.
We observed the support people received during the lunchtime period. The atmosphere was warm and friendly with staff talking, laughing and singing with people. Where people needed assistance with eating and drinking staff provided support appropriate to meet each individual person’s assessed needs. People were given plates and cutlery suitable for their needs and to enable them to eat independently wherever possible. People and their relatives told us, "The meal I had today was lovely", "They serve lovely food", "You get a good choice of food", "The food on the whole is not too bad", "The chef made me Lasagne especially just for me" and "Mum does well with her eating, especially as she is on a soft diet."
There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and told us they felt supported by the management team. Comments from staff included, “Pretty good working here” and “The manager has been helpful and listens to us.”
People and relatives all described the management of the home as open and approachable. Comments included, "The manager is brilliant" and "I wouldn't move anywhere else." There were regular meetings for people and their families, which meant they could share their views about the running of the service. People and their families were given information about how to complain.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.