The Knowles

The Knowles is a residential care home providing personal care for to up to 38 people. The service provides support to younger and older adults some of whom are living with dementia. At the time of our inspection there were 36 people using the service and 2 people were in hospital.

People’s experience of using this service and what we found

Fire safety risks were not always identified or responded to in a timely way. Some audits and checks to monitor the safety of the service were not always effective as they failed to identify the issues we found, for example issues around infection control and prevention. People felt safe living at The Knowles. People received their medicines safely, when needed by staff trained in medicines management. Staff were recruited safely.

A range of quality monitoring systems were in place; however, further improvement was needed. We made a recommendation to implement robust systems and checks to monitor the safety of the service. The registered manager and staff team demonstrated their commitment to ensuring people received a quality service and worked with other professionals to achieve good outcomes for people. Staff felt supported by the management team.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 26 May 2022).

Why we inspected

We received concerns in relation to the staffing levels and culture of the service. As a result, we undertook a focused inspection to review the key questions safe and well led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvements based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider took immediate action to make improvements to mitigate any risks to people.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for The Knowles on our website at www.cqc.org.uk.

We identified a breach in relation to assessing and managing safety risks within the environment.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Knowles is a residential care home providing personal care to up to 38 people. The service provides support to older and younger adults some of whom are diagnosed with dementia. At the time of our inspection there were 35 people using the service.

People’s experience of using this service and what we found

People told us they were happy living at The Knowles. Peoples' risks were assessed and regularly reviewed. Peoples' care plans gave staff clear direction of how to support people to manage risk safely. Systems were in place to ensure safeguarding concerns were identified and reported appropriately. People received their medicines safely and staff administering medicines had been trained and assessed as competent to do so.

Staff were recruited safely and there were enough staff to meet peoples' needs. The service was adhering to current UK Government guidance relating to the management of Covid-19.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Systems had been implemented to ensure the quality of the service was monitored and regulatory requirements were met. This included daily, weekly and monthly monitoring and a range of audits across the service which had been regularly completed. The provider had strengthened reporting systems and received structured and detailed reports from the manager on a regular basis. People, relatives and staff were regularly asked for formal and informal feedback which helped to drive improvements in the service.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 31 October 2019).

At our last inspection we found breaches of the regulations in relation to safe care and treatment and good governance of the service. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was now meeting this regulation.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 17 September 2019. Breaches of legal requirements were found in relation to Safe Care and Treatment and Good Governance.

We undertook this focused inspection to check if the provider had made improvements and if they were now meeting the legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Knowles on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Knowles is a care home and was providing personal care to 33 people at the time of the inspection visit. Two people who lived there were in hospital. The majority of people who live at the home are older people living with dementia. The service can support up to 40 older people or younger adults with dementia care needs. Accommodation is in an adapted building over two floors.

People’s experience of using this service and what we found

Systems to monitor the quality and safety of the service had not been fully effective in identifying areas for improvement and ensuring areas of risk were promptly acted upon. Risks associated with people’s care were not always effectively recorded and managed. This included risks related to the management of falls and people’s behaviours that were challenging. Some people’s care plans lacked detail to support staff in keeping them safe.

People were provided with a choice of meals but gave mixed reviews of the food provided. Staff supported those people who needed assistance to eat and specialist diets were catered for. However, records did not always confirm dietary advice provided by health professionals was followed.

Staffing arrangements were not consistently effective to keep people safe. Whilst people were complimentary of staff, they felt at times support was delayed. This in particular applied to at night when staff numbers reduced, and communal areas were not always supervised. This increased the risk of people’s safety not being maintained and there were people who had sustained unwitnessed falls during this time.

People received their medicines, but medicine checks showed discrepancies in medicine counts. This meant it was not possible to confirm the amount of medicine administered and remaining was correct to confirm medicines were managed safely. Medicines were stored safely.

The service had a registered manager in post but at the time of our inspection they were absent from the home and the provider had arranged for a member of the management team to support the home. People and relatives knew this staff member and spoke positively of them during our visit.

Peoples needs were assessed prior to them starting to use the service and were involved in making decisions about their care and how they would wish to be supported. Where appropriate family members were also involved in this assessment.

Staff understood how to recognise abuse and knew they had a responsibility to report any concerns to their manager, so these could be addressed. People told us they felt safe and felt at ease to report any concerns to staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff had been recruited safely and staff received the training they needed to support people needs. Staff felt the training they received was effective. Staff spoke kindly of people and knew people well, so they could provide care in the way people wanted.

People told us staff were kind and caring and treated them with dignity and respect. We saw staff were respectful towards people and encouraged them to maintain their independence. People had access to a range of activities which were of interest to them including some outside visits. Visitors were welcomed into the home and spoke positively of the service.

People knew who to contact if they had any concerns. The provider had a system for responding to complaints and those received had been responded to and resolved.

People spoke positively about the management team and had confidence in them. Staff felt valued which had resulted in a positive, encouraging and supportive culture which benefited all. The management team demonstrated a commitment to further improve the service.

People and staff had opportunities to comment on the service during meetings and periodic quality satisfaction surveys. Health professionals were also invited to provide their views though these surveys.

Since the last inspection, action had been taken to ensure notifiable incidents such as serious accidents and incidents were reported to us as required.

Appropriate action had been taken by the provider to display their ratings.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was Requires Improvement (published 26 September 2018) and there were multiple breaches of the regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

The inspection was prompted in part by notification of a specific incident. A person using the service sustained a serious injury. This incident is subject to an investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of falls. This inspection examined those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Responsive and Well Led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Knowles on our website at www.cqc.org.uk.

Enforcement

We identified two breaches in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations. Insufficient action had been taken to mitigate risks associated with people’s care to keep people safe, and systems to monitor the quality of the service, were not always effective. We have found evidence that the provider needs to make improvements across the Safe and Well led key questions.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Knowles is a residential care home which provides accommodation and personal care to older people including those living with dementia. It is registered to accommodate a maximum of 38 people. On the days of our inspection visits there were 33 people living in the home.

People in care homes receive accommodation and 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 accommodation is set out over two floors, the first floor being reached by a lift. There are three separate lounge/dining areas and an accessible garden.

There was a new manager in post but they were not 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 manager took up their post on 22 August 2018, in between our two inspection visits. The deputy manager had been ‘acting manager’ and had returned to their original role.

At our previous inspection in April 2017, we rated the service as Requires Improvement. This was because the service was not as consistently safe, effective or as responsive to people’s needs as it should have been, and the service was not consistently well led. For example, risks to people’s care were not always managed safely. People did not always receive personalised care and at times staff did not respond to people’s needs in a timely way. How quality monitoring systems were implemented did not ensure the home was consistently well led.

At this inspection we found some areas of improvement. However, we also identified some issues that meant the service remains rated ‘Requires Improvement’ overall.

Incidents had not always been appropriately recorded or investigated to identify how safety issues could be resolved. The lack of completed incident reports, meant the manager had not been able to investigate and categorise the incidents to see if a referral to the local safeguarding authority was appropriate. The provider had not notified us of all the safeguarding referrals that had been made to the local authority in accordance with their legislative responsibilities. The provider’s quality assurance systems had not identified these issues.

There were enough staff to provide safe care, but staff were very busy and sometimes did not have time to engage with people as they wished to. The suitability of staff was checked during recruitment procedures to make sure they were safe to work at the home. Staff received an induction and training to ensure they had the knowledge and skills to meet people’s needs effectively.

The provider used a range of recognised risk assessment tools to identify people’s individual risks, but there was inconsistency in the level of information staff had to manage risks. Records to evidence risk management needed to be improved.

People had an assessment completed before moving to the home to make sure staff could meet their care and support needs. People’s healthcare needs were monitored by staff and any concerns were referred to other healthcare professionals. People’s medicines were managed, stored and administered safely.

Since our last inspection the provider had reviewed the nutritional support people received and introduced some initiatives to ensure people had enough to eat and drink and had a more enjoyable lunchtime experience.

People appeared to be happy living at the home and during our visit we saw some genuine, empathetic and kindly interactions between staff, people and relatives. Staff treated people with dignity and respect and were helpful towards each other in completing their care duties and supporting people.

Staff and managers worked within the principles of the MCA (Mental Capacity Act 2005) and DoLS (Deprivation of Liberty Safeguards) legislation. People's capacity to make decisions had been assessed, and DoLS applications made as required.

The new manager had experience of providing dementia care and was keen to provide a homely environment where people experienced high standards of care. They explained the importance of staff spending quality time with people by making care tasks more interactive.

The provider had an action plan to improve the quality of care provided within the home. They planned to introduce an electronic care planning system so staff had immediate access to information about people and could record care interventions at the time of delivery. A refurbishment was planned to address cleanliness issues and improve the environment for people living with dementia.

There were three breaches of the regulations. You can see what action we told the provider to the back of the full version of the report.

The Knowles is a residential care home which provides accommodation and personal care to older people including those living with dementia. It is registered to accommodate a maximum of 38 people.

On the days of our inspection visits there were 32 people living in the home. There was one person who was in hospital.

There was a new manager in post but they were not 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 provider had ensured the home was supported by a ‘compliance’ manager from within the organisation in the absence of a registered manager. The new manager who is referred to throughout this report as the “care manager” had been in post for one week at the time we carried out our inspection.

People living at The Knowles told us they felt safe. Care staff understood their responsibilities in being observant at all times to keep people safe. However, there were periods of time when communal lounges were not occupied because staff were needed to support people elsewhere in the home. This placed some people at increased risk of falling due to them not waiting for staff assistance to walk. There had been a high number of falls in the home and it was not evident these were always effectively managed.

Staff knew how to recognise abuse or poor practice and told us they would report abuse if they observed this happening. We found that not all reportable incidents related to people’s health and safety had been reported to us. We found that information related to risks associated with people’s care was not always clearly recorded and risks were not consistently managed.

There was a computerised medicine administration system in place. Records related to creams and lotions did not reflect these had always been applied as prescribed.

There were recruitment checks and systems in place to ensure staff were safe to work with people at the home. Staff received an induction to the service when they started work. They also had access to a range of training to maintain and update their skills and knowledge so they could meet people’s needs safely and effectively. Staff practice was observed and they had supervision meetings so their competence could be assessed to ensure they worked to the provider’s policies and procedures.

Staff had been supported with training to help ensure they understood how people who lacked capacity could be supported to make decisions. Staff knew they could not undertake care practices against the wishes of people in the home. The management team had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People had been assessed to determine how decisions could be made in their best interests and applications for DoLS had been completed. Authorisations that had expired had been reapplied for.

We observed staff were caring in their approach and people considered staff to be kind and caring. Most of the time, when staff were available in the communal areas, they were responsive to people’s needs.

Social activities were provided for people and work was ongoing to ensure these were meaningful activities for the varying needs and dependencies of people at the home. Staff knew about people’s wishes and preferences in relation to their care and aimed to support people in accordance with these.

People were provided with a choice of food and drinks. Drinks were regularly provided throughout the day and people were satisfied with the food provided. However, where people had lost weight and there were concerns regarding their health, action taken had not always been sufficient or effective in addressing these concerns.

People had access to health professionals when needed and district nurses visited the home on a regular basis to support people’s healthcare needs.

People and their relatives were encouraged to provide feedback about the quality of care and services in the home. Quality satisfaction questionnaires seen showed mostly positive responses. Where negative feedback had been given, this had been acted upon. People and visitors stated they would feel comfortable raising any concerns if they needed to. We saw complaints made had been appropriately responded to.

There were processes and systems to check the care and services provided were in accordance with the provider’s policies and procedures. Some of these checks were not sufficient in ensuring safe and effective care was provided.

People and relatives were positive in their comments of the management team and staff told us they enjoyed working at the home.

We found there were 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 the report.

During our visit we spoke with six people and one visitor. Many of the people who lived at The Knowles had dementia so we also observed what their experiences were like across the three lounge/dining areas in the home. People we spoke with told us they were satisfied with the care they were receiving. Comments included: 'They look after me ok here'. 'It's alright, I like it here'.

People told us they liked the meals and enjoyed the entertainment provided. Social events planned were displayed on the notice board in the home.

During our last inspection we found improvements were needed to ensure compliance with the standard relating to records. During this inspection we found sufficient improvements had been made. Care plans for people provided staff with sufficient information to deliver care safely. Where there were risks associated with peoples care such as falls, risk assessments had been completed to assess and manage these risks.

The service had systems in place to ensure medication was administered safely.

We saw that staff had access to regular training to ensure they had the skills to deliver care safely and appropriately to people. Newly recruited staff had completed full induction training.

The service had processes in place to gather the views of the people and visitors to make sure the quality of service provided was in accordance with their expectations.