This inspection visit took place on 13 and 15 November 2018. The first day of our inspection visit was unannounced.

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 coul

Castle Brook provides accommodation and personal care for up to 84 older people who may live with dementia. Sixty-three people were living at the home at the time of our inspection visit. This was the first comprehensive ratings inspection since the service was registered on 2 December 2016.

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