We carried out an unannounced inspection of Castle Hill House on 13 November 2018. Castle Hill House is a ‘care home’ that provides nursing care for a maximum of 43 adults. 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. At the time of the inspection there were 27 people living at the service. Some of these people were living with dementia. The service is a detached house over two floors. The ground floor was dedicated to people receiving nursing care and the first floor was mostly for people with residential needs. There was a passenger lift to support people to access the upper floor.

The service is required to have a registered manager and at the time of the inspection a registered manager was not in post. However, a new manager was appointed in November 2017, when the previous registered manager left their post. This manager had an application to become the registered manager being progressed and nearing completion. 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.

As part of this comprehensive inspection we checked to see if the provider had made the required improvements identified at the inspection of 31 October 2017. In October 2017 we found 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. Some of the areas for improvement found at that inspection had been identified through the service’s own auditing system. However, action had not been taken to make the necessary improvements. The rating at the last inspection was Requires Improvement.

At this inspection we found improvements had been made in all the areas identified at the previous inspection. This meant the service had met all the outstanding legal requirements from the last inspection and is now rated as Good.

There were safe arrangements in place for the storing and administration of medicines. People were supported to take their medicines at the right time by staff who had been appropriately trained. Medicine Administration Records (MARS) were completed appropriately and there were no gaps in the records.

There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people's changing needs and wishes. Since the last inspection, changes had been made to the way staff were deployed. Staff were allocated to work with specific people for the duration of their shift, which meant people’s needs could be met in a timely manner. The timing of staff breaks was more flexible to consider busy times and to be more responsive to people’s needs.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Staff demonstrated the principles of the MCA in the way they cared for people. The service had carried out assessments of people’s mental capacity and decision making ability in line with the legal requirements of the MCA. Where people did not have the capacity to make certain decisions the service acted in accordance with legal requirements.

People received care and support that met their needs because there was a stable staff team who had the skills and knowledge to provide responsive and personalised care. Staff knew how to recognise and report the signs of abuse. People and their relatives told us they were happy with the care they received and believed it was

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

Castle Hill House Care Home with Nursing provided care and support to a maximum of 43 people. There were 32 people using the service at the time of our inspection. There were seven rooms being renovated at the time of our inspection therefore one wing of the home, where the renovations were taking place, did not have anybody living in it.

We saw people’s privacy and dignity were being maintained.

We saw care plans were detailed and gave direction as to the care and support people needed. They had been regularly reviewed.

There were robust and up to date infection control policies and procedures available to staff at all times. The home was clean and tidy at the time of the inspection.

The premises were well maintained. Peoples own rooms were personalised to their own taste.

We saw staff were able to meet people’s nursing and care needs but some people were sometimes left in the communal area or walking around the home without supervision. There was no activity organiser at the time of the inspection and although care workers were carrying out some activities people did spend periods of time without social stimulation. People who used the service told us outside entertainers visited the home sometimes.

There were robust systems in place to monitor the quality of the service.

We spoke with two people who used the service and one relative. They all said they liked it at Castle Hill House. We saw people in communal areas interacting with the staff, and from the verbal and non-verbal communications seen we understood staff to be attentive, helpful and polite. The atmosphere in the home was warm and welcoming.

Care plans and associated documentation were in place. They had sufficient detail in them to direct and guide staff of the action they needed to take in order to meet people’s assessed care needs. People's records were personalised, and showed choices were made by people in respect of their daily lives.

People were protected from the risks of inadequate nutrition and dehydration.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

We did not speak directly to people who use the service during this visit as it was lunchtime.

We saw staff engaged with people helping them with moving about the home and providing personal care and support.

We asked some of the people using the service about life at Castle Hill House. They told us they choose what they do each day, for example, they go to bed and get up when they like and there are activities they can join in if they wish.

They said that they were very satisfied with the care and support they received and they liked the flexibility and the fact the staff don’t keep them waiting if they need some help.

People told us that the staff are kind and caring and they felt safe in the home. They said there would be no problem voicing concerns to staff or the manager if the need arose.

They said there ‘seems to be enough staff’ working in the home and that ‘the staff are all lovely and do a good job’

The inspection took place on 18 and 19 August 2015 and was unannounced.

Castle Hill House Care Home is registered to provide nursing care for a maximum 43 older people who have nursing and or mental health needs. On the day of the inspection 34 people were using the service.

The service had a registered manager in post. 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.

Medicine administration records were in place but had not all been completed correctly. An action plan had been put in place to address the issues found. The registered manager and providers told us that they would be implementing a new policy in the near future. People were supported to maintain good health through regular access to healthcare professionals, such as GPs, speech and language therapists and dieticians.

Care records were personalised and gave people control over all aspects of their lives. People and those who mattered to them were involved in identifying how they would like to be supported and in regularly reviewing their support and care needs. People's preferences were sought and respected. The registered manager told us "the care staff have the needs of our residents at the top of their list." Staff responded quickly to people’s change in needs.

People told us they felt safe.  All staff had undertaken training on safeguarding vulnerable adults from abuse. They knew how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated.

People were protected by the service’s safe recruitment practices. Staff underwent the necessary checks which determined they were suitable to work with vulnerable adults, before they started their employment. Staff received a comprehensive induction programme. There were sufficient staff to meet people’s needs. Staff were appropriately trained and had the correct skills to carry out their roles effectively.

During the inspection people and staff were relaxed, the environment was clean and tidy. There was a calm and pleasant atmosphere. People confirmed they had the freedom to move around as they chose and enjoyed living in the home. People as much as they were able to or, where appropriate those acting on their behalf, spoke highly about the care and support they received. Relatives told us, "I looked at two homes for my mum. Straight away, I knew this was the one" and "My mum wouldn't want to go anywhere else." The registered manager told us "Customer care is of paramount importance."

Staff described the management as supportive and approachable. Comments included, "the registered manager is very hands on, helps with personal care and attends handover every morning." Staff talked positively about their jobs, "I love it, it's a friendly place to work and you don't feel pressured."

People and those who mattered to them knew how to raise concerns and make complaints. Any complaints made were thoroughly investigated and recorded. Learning from incidents and concerns raised was used to help drive improvements and ensure positive progress was made in the delivery of care and support provided by the service. There were effective quality assurance systems in place to identify where improvements could be made to improve the quality of care.