Knowle House Nursing Home is registered to accommodate up to 33 people who require support with personal and nursing care. It specialises in providing support to older people. At the time of our visit there were 23 people living at the service. The service had 19 single rooms and eight shared rooms. Only one of the shared rooms was occupied by two people who had lived at the service for a number of years. Accommodation is provided across three floors with the first and second floors accessed via a shaft lift. There is level access throughout the building and grounds.
The service had a 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. In this service the registered manager is also the registered person.
We carried out an unannounced comprehensive inspection of Knowle House Nursing Home on the 8 September 2015. As part of this inspection we checked what action had been taken to address the breaches of legal requirements we had identified at our last inspection on 19 November 2014. After our last inspection, the provider wrote to us to say what they would do to meet legal requirements and sent us an action plan detailing how they intended to ensure they met the requirements of the law. At this inspection we found improvements had been made and sustained and all the breaches previously identified had been addressed.
Without exception the feedback about the management of the service and the improvements made was positive. The provider had employed a new registered manager who started work at the service at the beginning of January 2015 who had overseen the implementation of the provider’s action plan and taken steps to ensure the improvements were embedded into everyday practice. One relative said, “There were huge problems in the past with the management continually changing. Now they’ve got a permanent manager who is brilliant and a deputy, which they needed, it’s great. The manager has made a huge difference”. Another relative said, “There have been big improvements in the management. I’m very impressed with the place and the care and attention given. Other people seem happy and contented too”. A staff member said, “I think the manager is really good. They’re so easy to talk to and will always listen”. Another staff member told us, “The manager is really friendly but at the same time, really clear that the residents come first. You know where you stand”. Staff felt management were supportive. They told us there was a positive and open culture and enjoyed coming to work.
Improvements had been made in relation to the arrangements in place for people to give their views on the service. People and their relatives were able to contribute to meetings and make suggestions concerning their welfare and future service provision. One person told us, “We have club meetings about what we’ve done, do we want to improve it and make it better or do we want to scrap it all together. The secretary takes the minutes and gives us a leaflet about it for us to think about.” A relative told following our last inspection the provider had called a residents and relatives meeting at which the provider, “Invited questions about the inspection and asked for suggestions from people about improvements they could make which they took on board.”
Action had been taken to improve the safe management of people’s medicines. The arrangements in place for the ordering, storage and administration of people’s medicines were safe and people received their medicines when they needed them. A visitor told us their relative had their medicines on time and said, “I visit regularly and know the tablets are always given on time. The patches are given right down to the minute.”
Improvements had been made in relation to the protecting people against the risk of abuse. People and their visitors told us they felt safe and raised no concerns about their safety. Staff were aware of what constitutes abuse and had completed relevant training. The registered manager and staff had a good understanding of the protocols for making a safeguarding referral. Incidents that affected people's safety had been recorded and investigated. A relative told us, “I’ve never heard or seen anything going on that I needed to say anything about and I would have no reservations in doing so.” A staff member said, “If someone was handling someone roughly, then I would go straight to the manager or to Social Services if I had to”.
Improvements had been made to the safety and delivery of care people received. Risks had been appropriately identified and robustly addressed in relation to people’s specific needs. For example assessments of people’s risk of falls and developing pressure areas had taken place and strategies were in place to reduce these risk. There was constant monitoring and reassessment of risks which ensured that staff took actions to protect people for example we saw staff reminding people who needed to use walking frames to use them.
Improvement had been made in relation to planning people’s care. People and their representatives had been involved in the development of care plans which were centred on the person and detailed their likes and dislikes and where known, their personal histories. People’s needs and preferences were detailed such as whether they needed assistance to brush their hair and whether they liked to wear makeup and jewellery. A visitor told us they and their relative had been fully involved in compiling the care plan they said, “The care plan has been signed, sealed and delivered. That was one of the problems there had been, care plans were out of date. That is one of the things (registered managers name) did; make sure they were all redone and brought up to date.”
Improvements had been made in relation to making sure lawful consent had been gained from people for their care and treatment. Mental capacity assessments had been completed in line with legal requirements. Where people lacked the mental capacity to make decisions the management and staff were guided by the principles of the Mental Capacity Act 2005 (MCA) to ensure any decisions were made in the person’s best interests. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the registered manager understood when an application should be made and how to submit one. Deprivations of Liberty Safeguards (DoLS) authorisations were in place and care plans clearly identified if someone was subject to a DoLS.
Staffing levels had improved and were based on the individual needs of people. Staff were seen spending individual time with people and responding to call bells and requests for assistance quickly. A relative told us, “Whenever I visit, there are plenty of people around and they seem to have to time to talk to people”. One staff member told us, “We’re lucky I suppose. We have enough staff to cope and to spend time with the residents”. Staff recruitment ensured staff were suitable to work at the service. Relevant identity and security checks had been completed before staff were deployed to work.
Staff training and support had improved. Staff had completed training that was relevant to their roles and which provided them with the skills they needed to meet people’s needs. For example staff had completed training in the administration of medicines and supporting people living with dementia. One staff member told us, “I’d never done this type of work before so I did a lot of shadowing. I thought the induction was really good”. Another staff member said, “I learned a lot from the induction. I felt quite confident afterwards”. Staff received regular supervision where they could speak in confidence with their line manager about any concerns they may have and discuss their personal and professional development.
Improvements had been made to the quality assurance systems in place and internal audits the results of which were used to help drive improvements in the service. Accidents and incidents were recorded and the results analysed to identify and emerging themes and patterns, and action had been taken to reduce the risk of re-occurrence.
People’s dignity and privacy was protected. For example we saw staff knocked on people’s doors and waiting for a response before entering their rooms. Doors were shut when staff supported people with personal care and ‘Do not disturb signs were hung on the door’. People were seen to be appropriately covered throughout hoisting procedures, and were referred to by their preferred term of address.
Staff knew people well and had formed strong bonds with them. One person said, “We get on well; I have a laugh with the girls.” Another person said, “They are very lovely the girls so pleasant. They guide you and help you. A very happy bunch. Anyone can come in and have lunch with us if you want.” A visitor told us, “I come in at all times of day and days of the week. They would never know when I might call in but many times when I’ve turned up there has been a carer holding mums hand or talking to her”. They also said “They really did help me and mum to settle in. They built up her confidence bit by bit and eventually she started to come down (to the communal area) and now she’s really settled here”.
People were supported to make their own decisions and remain independent. One person told us, “I do things on my own and at my own speed, sometimes they chivvy me along but they don’t interfere.” A staff member told us, “I like to get people to make their own decisions if they can. For example, if someone doesn’t want to do something, then it’s up to them”. Another staff member told us, “We have to remember it’s their home. We won’t go wrong if we remember that”.
Visitors were welcomed and visiting times were not restricted. One visitor told us, “I really like the homeliness. They always ask me if I want a cup of tea or coffee. They keep me up to date when I visit or they ring me if anything has happened, they discuss everything with me. These girls are really caring”.
Staff were kind and respectful when interacting with people giving them time and space to respond to questions, and were patient when people wanted to speak and struggled to say what they needed. People looked comfortable and they were supported to maintain their personal and physical appearance. For example, people were well dressed and groomed. People could bring their own furniture and personal belongings to help them feel at home. Thought had been given to the decoration of people’s rooms and communal areas which had been decorated with wall paper which gave the rooms a domestic feel.
People enjoyed the meaningful activities provided. They liked the social aspect of activities and in particular when they took place in conservatory. One person told us, “The music’s good, we sing together, I like that. The activities that (activity organisers name) does are really good. We can make suggestions and decide together what we want to do.” A book of interest to the individual with a book mark stating, ‘Please read this to (person’s name) at every opportunity’ had been placed in the room of each person who spent a lot of time in their room. There were raised beds in the garden to enable people who liked gardening to use and a vegetable plot where seedlings people had grown had been planted.
People had a choice of food at meal times and specialist diets were catered for. People who needed help to eat and drink were supported appropriately. People’s weight was monitored and referrals were made for specialist health care support as needed. For example for Speech and Language Therapy and input from GP’s.
People had been provided with a guide to the service and were aware of how to raise concerns and complaints and felt able to do so. Complaints received had been recorded and responded to appropriately in line with the provider’s policy.