We inspected Castlemaine on the 04 and 05 October 2018. This was an unannounced inspection.

Castlemaine Care Home provides care and support for up to 42 older people living with dementia. The care needs of people varied, some people had complex dementia care needs that included behaviours that challenged. Other people's needs were less complex and required care and support associated with mild dementia and memory loss. Most people were fully mobile and able to walk around the home unaided. At the time of this inspection there were 21 people living at the home and one person receiving respite care. Respite care is a short term stay.

Following our inspection in November 2015 warning notices were issued. The provider sent us an action plan that told us how they would address these. We inspected again in September 2016 to check the provider had made improvements and to confirm legal requirements had been met. We found the provider had not addressed the breaches of regulation found. We also identified further breaches of regulation in relation to staff support, procedures for reporting safeguarding matters and deprivation of liberty. The provider sent us an action plan telling us how they would make improvements. We met with the provider and received two monthly updates on progress made in meeting the regulations. We inspected in May 2017 to check what progress the provider had made to ensure legal requirements were met. We found in May 2017 the provider continued to be in breach of legal requirements. We continued at that time with the enforcement pathway. In September 2017 we found that improvements had been made and the breaches of regulation met.

This inspection found that whilst improvements seen in September 2017 had not deteriorated, there had not been the necessary improvements to change the rating to Good.

This is the second consecutive time the service had been rated as Requires Improvement.

Whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. This included updating care plans when an identified need or directive of care changed. For example, a deterioration in mobility and nutritional needs.

Not all care plans had been reviewed and updated to ensure they reflected people’s current needs and associated risks. For example, changes to people’s nutritional needs due to swallowing difficulties had not been recorded accurately and placed people at risk from not receiving the correct consistency of food and therefore cause complications such as choking or aspiration. Changes to peoples' mobility had not been reflected in the care plan or risk assessments so agency and new staff would not have the correct information to support people safely.

Risk assessments included falls, skin damage, behaviours that distress, nutritional risks including swallowing problems and risk of choking, and moving and handling. For example, pressure relieving mattresses and cushions were in place for those who were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes. Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people when they needed assistance. The provider was actively seeking new care staff, to ensure there was a sufficient number with the right skills when people moved into the home. There were systems for the management of medicines and people received their medicines in a safe way. All staff had attended safeguarding training. They demonstrated a clear understanding of abuse; they said they would talk to the management or external bodies immediately if they had any concerns. Staff had a clear understanding of making referrals to the local authority and CQC. Pre-employment checks for staff were completed, which meant only suitable s

We inspected Castlemaine on the 13 and 14 September 2017. This was an unannounced inspection.

Castlemaine Care Home provides care and support for up to 42 older people living with dementia. The care needs of people varied, some people had complex dementia care needs that included behaviours that challenged. Other people's needs were less complex and required care and support associated with mild dementia and memory loss. Most people were fully mobile and able to walk around the home unaided. At the time of this inspection there were 21 people living at the home and one person receiving respite care. Respite care is a short term stay.

Following our inspection in November 2015 warning notices were issued. The provider sent us an action plan that told us how they would address these. We inspected again in September 2016 to check the provider had made improvements and to confirm legal requirements had been met. We found the provider had not addressed the breaches of regulation found. We also identified further breaches of regulation in relation to staff support, procedures for reporting safeguarding matters and deprivation of liberty. The provider sent us an action plan telling us how they would make improvements. We met with the provider and received two monthly updates on progress made in meeting the regulations. We inspected in May 2017 to check what progress the provider had made to ensure legal requirements were met. We found in May 2017 the provider continued to be in breach of legal requirements. We continued at that time with the enforcement pathway.

At this inspection improvements had been made and the breaches of regulation met. However, there were areas that needed further development and embedding into everyday care. Since the last inspection a consultant had been employed to offer guidance and support. The local authority had continued to provided support and the providers had increased their visits and monitoring of the home

There was no registered manager in post. Following the inspection in May 2017, the registered manager resigned from the post. The deputy manager had taken the post of acting manager and was in the process of submitting their application to be the registered manager. 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.

At this inspection there was strong managerial oversight to ensure documentation was kept up to date and ensured people received safe, effective, caring and responsive care. A range of audits had been introduced and completed monthly. When audits had identified issues there was evidence of recorded actions taken to address the issues. For example, the poor recording of fluid intake for some people had led to the introduction of new fluid charts. We still found some inconsistencies and these will be addressed further within staff’s individual performance supervisions. Accidents and incidents whilst audited did not fully record the actions taken and how these were monitored to prevent a re-occurrence.

This inspection found the management and storage of medicines were safe. There were areas to further develop in respect of the management of ‘as required’ (PRN) medicines and these were immediately actioned. Risks related to fire safety had been reviewed and advice sought as required. Action plans to address the issues around fire safety had progressed with two actions to be completed this month. Fire safety was now effectively managed.

Staff deployment during meal services was found in need of review on the first day of this inspection as it impacted on the support given to people. This was immediately reviewed when identified and on the second day improvements were visible. This will be continuousl

Castlemaine Care Home provides care and support for up to 42 older people living with dementia. The care needs of people varied, some people had complex dementia care needs that included behaviours that challenged. Other people’s needs were less complex and required care and support associated with mild dementia and memory loss. Most people were fully mobile and able to walk around the home unaided. At the time of this inspection there were 22 people living at the home and one person in receipt of respite care.

Following our inspection in November 2015 warning notices were issued. The provider sent us an action plan that told us how they would address these. We inspected again in September 2016 to check the provider had made improvements and to confirm that legal requirements had been met. We found that the provider had not addressed the breaches found. We also identified further breaches in relation to staff support, procedures for reporting safeguarding matters and deprivation of liberty. The provider sent us an action plan telling us how they would make improvements. We met with the provider and received two monthly updates on progress made in meeting the regulations. This inspection was carried out to check what progress the provider had made to ensure legal requirements were met. We found the provider continued to be in breach of legal requirements. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

There was 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.

At this inspection there was a lack of managerial oversight to ensure that documentation was kept up to date and ensured that people received safe, effective, caring and responsive care. The audit systems had not identified the matters we raised during this inspection. For example, it did not identify the shortfalls we found in relation to the management of medicines. Some matters identified at our last inspection had been addressed, for example new audits had been introduced. However, matters raised as a result of these audits were not always followed up. For example, actions to address recommendations from the medicine’s audits had not been completed.

The provider’s action plan included two monthly updates that told us improvements had been made. A number of improvements had been made. For example, each person’s needs in relation to how they would be supported in the event of an emergency had been assessed. However, no overall assessment had been made to determine how this would work in practice. Improvements had been made to record keeping in relation to health and safety. However, the provider told us that care plans had been audited. At the time of inspection we were told that no audits had been carried out. They said they would ensure fluid charts were completed accurately by April 2017. The last update stated that this would be ongoing.

There was no effective system to accurately monitor that people who had been assessed at risk of dehydration received enough to drink. There were no records that staff checked pressure relieving mattresses and cushions for two people at risk of developing pressure sores. We found both had been set at levels that were not in line with the people’s individual needs and this increases the risk of people developing pressure areas.

There were unsafe procedures for the storage, handling and disposal of medicines. There was no protocol for the safe administration of one person’s medicine that was prescribed to be given on an as required basis. This meant it was given every morning without an assess

Castlemaine Care Home provides care and support for up to 42 older people living with dementia. The care needs of people varied, some people had complex dementia care needs that included behaviours that challenged. Other people’s needs were less complex and required care and support associated with mild dementia and memory loss. Most people were fully mobile and able to walk around the home unaided. At the time of this inspection there were 22 people living at the home and another three people received respite care.

At our last inspection on 24 and 25 November 2015 we found improvements were required in relation to safety and governance. Warning notices were issued and the provider was required to be complaint in these areas by February 2016. We also issued a requirement notice in relation to staffing numbers. The provider sent us an action plan that told us how they would address these. We carried out this unannounced inspection on 14, 15 and 22 September 2016 to check the provider had made improvements and to confirm that legal requirements had been met. We found that the provider had not addressed the breaches found at the last inspection. We also identified further breaches in relation to staff support and procedures for reporting safeguarding matters.

There was 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.

There was no advice in some people’s care plans about how to evacuate them in an emergency or in the event of a fire. In others, the advice was not up to date. Record keeping in relation to the management of behaviours that challenged were not effective. In some cases incident reports had not been written, those that had, had not been properly evaluated and management were not aware that some had occurred. As a result there was no learning from these incidents and care plan documentation had not been updated. Risk assessments were updated monthly but not as and when people’s needs changed. There were no risk assessments in place for some people.

There was a high turnover in the staff team and a high use of agency staff. There was no effective or timely monitoring of the impact this had on the staff team. Senior staff did not feel supported or listened to. They told us that physical assaults were often a daily occurrence and they had stopped reporting matters as they felt that nothing was done about them. Management did not have an understanding of the numbers and severity of incidents that occurred in the home.

Some of the staff team had not received appropriate training to meet people’s needs. A number of staff had not received regular supervision and staff did not feel valued. Some staff did not have an understanding of the Deprivation of Liberty Safeguards (DoLS) and whilst they knew some people had a DoLS in place, they were not clear about others. (A DoLS is used when it is assessed as necessary to deprive a person of their liberty in their best interests and the methods used should be as least restrictive as possible).

Although some improvements had been made to increase the level of auditing we found that matters had not always been addressed once identified. For example, water temperatures in wash basins had been above safety requirements but no action had been taken. There were no care plan audits and no cleaning audits in place. Although we were told that the provider visited the home regularly there was no documented evidence that they checked on the running of the home.

Despite the shortfalls we found that people were happy with the service provision. Relatives told us, “The staff cheerfulness and devotion is the best thing about the place.” Another told us, “I’ve only ever seen (m

In this report the name of the nominated individual appears as Lynda Patricia Whitfield. This person was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a nominated individual on our register at the time.

Not all of the people who lived at the home were able to speak to us because of their dementia type illnesses. We used a number of different methods to help us understand the experiences of people using the service. We spoke to visitors to the home and we observed staff engaging with people.

People who could talk to us told us they enjoyed living at the home. One person said, “I am very happy here.” Another person told us, “the food is lovely, but I am getting a bit fat.” Visitors to the home told us the care their relatives received was good. One visitor told us, “I am very happy with the care and I can always speak to the staff.” Another person told us, “staff are really kind and good to the residents, they are genuine, it’s not put on.”

People received their medicines safely and in a timely manner because there were appropriate arrangements in place to manage medicines.

There was enough staff on duty to ensure people received an appropriate level of care.

We spoke to people using the services but their feedback did not relate to the standard we inspected.

We used a number of different methods to help us understand the experiences of people using the service, because most of the people using the service had complex needs which meant they were not able to tell us their experiences.

However, those we spoke with told us they were happy to live at the home. They told us staff knew them well and treated them with respect. People we spoke with told us they wouldn’t want to live anywhere else. When talking about staff one person said “they are a good bunch here” One person who had not lived at the home very long told us that staff already knew them very well. People told us they were very happy and well looked after. Some people said that the food was “really good” and it was “special”. People told us that they had a choice of meals. Visitors that we spoke with told us that food was good and their relatives always had a choice.

We spoke with five relatives. They told us they were happy with the care provided at the home. They said they were involved in care plan reviews, and were kept informed of any concerns related to their relative. Visitors that we spoke with told us that food was good and their relatives always had a choice.

Due to the complex needs of the people accommodated we did not discuss this area with the residents.

It was not possible to interview many of the people who live in the home due to their dementia type illness as they were not able to engage with the process.

We spoke to two people using the service, who told us that they were happy with the care they received and that they enjoyed the food.

We spoke to two visitors to the home who told us that they were happy with the care that their relatives received and had signed consents to care, treatment and support. The visitors told us that were kept informed of all health issues relating to their relatives.

It was not possible to interview many of the people who live in the home due to their dementia type illness as they were not able to engage with the process.

We spoke to two people using the service, who told us that they were happy with the care they received and that they enjoyed the food.

We spoke to two visitors to the home who told us that they were happy with the care that their relatives received and had signed consents to care, treatment and support. The visitors told us that were kept informed of all health issues relating to their relatives.

We spoke with four people using the service, who told us they were happy with the care they received, but that they had not been consulted about their likes, dislikes and preferences and had not been asked to sign consent to their care or risk assessments. They told us that staff respected their privacy and dignity and that staff were kind to them. People said that they liked the food in the home. They told us that they felt safe and secure in Castlemaine Care Home.

When we carried out an unannounced comprehensive inspection at Castlemaine Care Home on the 06 and 11 November 2014, breaches of Regulation were found. As a result we undertook an inspection on 23 and 24 November 2015 to follow up on whether the required actions had been taken to address the previous breaches identified. We had also received concerns from a whistle blower about staffing levels, increase of falls and poor moving and handling of frail people, which we looked at during this inspection.

Castlemaine Care Home provides accommodation and personal care for up to 42 people living with differing stages of dementia who also have health needs, such as diabetes. Castlemaine Care Home is owned by Alpha Care Castlemaine Limited who have one other care home in Kent. Accommodation was provided over two floors with a passenger lift that provided level access to all parts of the home. People spoke well of the home and visitors confirmed they felt confident leaving their loved ones in the care of Castlemaine Care Home.

After our inspection of November 2014, the provider wrote to us to say what they would do to meet legal requirements in relation to assessing and monitoring the quality of service provision, safeguarding, delivering appropriate care and did not have suitable arrangements in place for obtaining, and acting in accordance with, the consent of service users.

We inspected Castlemaine Care home on the 23 and 24 November 2015. There were 26 people living at the home on the days of our inspection.

Whilst we found improvements had been made to meet the previous breaches, we found regulation 17- Good governance was not fully met and breaches of other regulations.

We had received a number of concerns from various sources prior to the inspection. These concerns were regarding low levels of staffing, increased number of falls and unsafe moving and handling practices. We found there were concerns in these areas during our inspection.

Some people made complimentary comments about the service they received. People told us they did feel safe and well looked after. However, our own observations and the records we looked at did not always match the positive descriptions people had given us. Some of the relatives we spoke with were happy with the service being provided and others had concerns about staffing levels, “Staff seem to be rushing, it can get very busy in the afternoons.”

The provider did not have an effective system to check how many staff were required to meet people’s needs and to arrange for enough staff to be on duty at all times. Staff told us and we observed that there were not enough staff to meet people’s needs. We saw that people on the first day of the inspection were not supported with their meals and drinks. People were left unsupervised in communal areas and interaction between staff and people was rushed. People then exhibited signs of frustration and mental withdrawal.

Staff told us the home was usually well managed but changes in the service lately had caused staff to be concerned and they felt communication systems were failing. They told us that they had raised written concerns and were waiting for a response on the first day of our inspection. The provider confirmed that he had received the letter of concerns that day and that was the reason for his arrival at the home.

Quality assurance systems had not been effective in recognising shortfalls in the service. Improvements had not been made in response to accidents and incidents to ensure people’s safety and welfare. Accidents records identified an increased number of unwitnessed falls in October 2015 to November 2015. These had not been followed up with a plan of action to prevent a reoccurrence.

People’s weights were being monitored accurately to make sure they were getting the right amount to eat and drink, However the recent lack of appropriate support at meal times meant there was a risk of people experiencing malnutrition and dehydration. There were mixed views about the meals, some people were complimentary but other people were not so impressed. One person told us, “I can’t eat this, it’s too difficult to manage on my own.” A visitor said, “I come at meal times because the staff struggle to help everyone, so I help my mother.”

There were a wide range of person specific care plans and risk assessments in place. However we found that some peoples increased health needs had not been reflected in their moving and handling risk assessments which had the potential to put the persons and staff members’ safety and well-being at risk. .

Advice from health care professionals had been sought in a prompt manner when people showed signs of illness.

Records relating to people’s care and the management of the service were well organised and safely maintained.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. At the time of the inspection, the registered manager had applied for DoLS authorisations for people living at the service. Staff had a good knowledge of their responsibilities with the procedures of the Deprivation of Liberty Safeguards and were aware that people had had applications to have their liberty deprived. Procedures had been followed in relation to the Mental Capacity Act 2005. People had been supported to complete a mental capacity assessment before decisions were made on their behalf. A mental capacity assessment determines if a person has the capacity to make specific decisions about their lives.

Staff had received the essential training and updates required to meet people’s needs. This included training in the Mental Capacity Act 2005 (MCA) and preventing and managing behaviours that were a risk to the person or others.

People were protected from the risk of abuse. Staff had received training or guidance relating to the protection of vulnerable adults. Staff were clear of the actions they should take if they identified or suspected abuse. They were also aware of whistle blowing procedures to raise concerns.

Safe recruitment procedures had been followed to make sure staff were suitable to work with people. These checks ensure people were safe to work with vulnerable people.

Information regarding complaints were easily accessible to people and their relatives. Complaints that had been raised had been recorded. There were systems to make sure prompt action was taken and lessons were learned to improve the service being provided.

People some of whom were living with dementia were usually provided with meaningful activity programmes to promote their wellbeing. Staff had worked together to provide communal environment that was colourful, comfortable and safe. There was visual signage that enabled people who lived with dementia to remain as independent as possible. People were supported to maintain their relationships with people that mattered to them. Visitors were welcomed at the service at any reasonable time.

We found that the management of medicines was safe and people received the medicines prescribed to support their health and well-being.

The delivery of care was based on people’s preferences. Care plans contained sufficient information on people’s likes, dislikes, what time they wanted to get up in the morning or go to bed. Information was available on people’s preferences.

People we spoke with were very complimentary about the caring nature of the staff. People and visitors told us care staff were kind and compassionate.

Feedback had been sought from people, relatives and staff. Residents and staff meetings were now being held on a regular basis which provided a forum for people to raise concerns and discuss ideas

The overall rating for this provider is ‘Inadequate’. It means that Castlemaine has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of 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 this report.