The Knolls Care Centre

We found the following examples of good practice.

• The registered manager was knowledgeable of the designated clinical lead at the doctor’s surgery and has a good working relationship with the team. Four nurses have been put forward to work with the GP surgery for the nurse practitioners’ course which would make them nurse prescribers and hopefully reduce waiting time for treatment and mitigate risks to enable interventions at an earlier stage.

• I-pads and facetime options are made available to those who are unable to have face to face visitors which is supported by staff. Window visits are encouraged to take place and in fine weather garden visits are accommodated and supervised by a staff member. At the front of the building the provider has a gazebo with seating for people and their visitors. In addition, the provider is changing the use of a cabin which sits in the grounds of the property to accommodate poor weather visits.

• We observed really good interactions between people and staff with high staffing ratios to enable positive well-being to be supported. There were access to several activities on offer for those who chose to meet individual preferences.

Further information is in the detailed findings below.

People’s experience of using this service:

We found significant improvements had been made to the service since our last inspection. The acting manager, with the support of staff and the provider, had worked very hard to address the issues identified at the last inspection.

People told us they felt the care and support they received at The Knolls was safe.

Risks to people were identified and monitored. Clear guidance was in place for staff on how to support people with these risks.

Staff understood their responsibilities to safeguard people from harm and how to report their concerns internally and externally to local safeguarding authorities.

Staff treated people kindly and there was a friendly atmosphere in the home. People`s personal information was kept confidential and their dignity and privacy was promoted and respected by staff.

Care plans had been fully updated and improved since the last inspection. They were detailed and personalised to give guidance to staff on how to support people effectively.

Medicines, including ‘as required’ medicines were managed safely and staff worked with other healthcare professionals to meet people’s health related needs.

People had enough to eat and drink and told us they enjoyed their meals.

People and their relatives were involved in discussions about their care.

Staff encouraged people to maintain their interests and take part in activities, and most people felt they had enough to do. Activities coordinators worked hard to identify ways to provide a range of activities that appealed to all.

There were enough staff to meet people’s needs. Staff had regular supervision and training in subjects considered mandatory by the provider to develop their skills and knowledge. Staff had additional training in relation to people’s specific support needs, such as dementia. Recruitment processes were followed to ensure suitable staff were employed to work at the service.

The provider`s governance systems and processes had improved and the acting manager had a clear plan in place to support ongoing improvements and support the new registered manager when they took up their post.

Rating at last inspection:

At the last inspection in December 2017 the service was rated ‘Requires Improvement’ with several breaches of regulations found. This inspection we found improvements had been made and there were no breaches of regulations.

Why we inspected:

This was a planned inspection based on the rating at the last inspection. The service has made significant improvements and is now rated Good with one ‘requires Improvement’ in the ‘Well-led’ domain because the requirement to have a registered manager was not met.

Follow up:

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

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

The Knolls accommodates up to 56 people in one adapted building across three separate units, each of which have separate adapted facilities. One unit is for people with nursing needs, the second is for people with residential needs and a third smaller unit provides rehabilitation support to people who have been discharged from hospital before they could go home. The service supported some people who live with dementia. At the time of the inspection there were 43 people living at the home.

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.

Medicines were administered safely, but stock was not always returned to the pharmacy in a timely manner.

People were supported to access health and social care services when required.

The provider did not have effective recruitment processes in place and some pre-employment checks were incomplete. There were sufficient staff to support people safely. Staff understood their roles and responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff gained people’s consent before they provided any care or support to them.

People were supported to have choice and control of their lives. However, checks to ensure people were supported in the least restrictive way possible were not always completed.

There were risk assessments in place that gave guidance to staff on how risks to people could be minimised although these had not been completed for all necessary aspects of some people’s care.

Staff supervision was not provided regularly and training to enable staff to support people well was not all up to date. The service had a plan in place to address this.

Some staff were not always kind or respectful to people although others were and we saw some positive interactions during the inspection. People were supported to pursue their interests and, particularly on the rehabilitation unit, were supported to maximise their independence.

Care plans took account of people’s individual needs, preferences, and choices and were reviewed regularly.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people and acted on the comments received to continually improve the quality of the service.

The provider did not have a clearly communicated set of values to underpin the service that were known or understood by staff. The registered manager was prioritising the development of a more person centred culture within the service.

Although the provider had quality monitoring processes in place to ensure they were meeting the required standards of care they were not always effective.

Notifications were not always sent to the Care Quality Commission as required by law.

At this inspection we found that the provider was in breach of some of the regulations 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.

The service provides accommodation and personal or nursing care for up to 56 people with a range of needs including those associated with dementia and with life limiting health conditions. At the time of our inspection there were 45 people living at the home. The service consists of a residential unit for people who do not require nursing care, a nursing unit and a step down (rehabilitation) unit for up to six people working towards going home following a hospital stay. At the time of our inspection, an additional six beds (from the nursing unit) had been commissioned for step down care, bringing the total number for this unit to 12.

The service did not have a registered manager, the previous manager having left the service approximately one year ago. 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 the time of the inspection a new manager had been appointed but had not taken up their post yet. There was an acting manager in post who was familiar with the service and held a senior management position within the provider organisation.

Staff were aware of the safeguarding process. Personalised risk assessments were in place to reduce the risk of harm to people, as were risk assessments connected to the running of the home. These were reviewed regularly. Accidents and incidents were recorded and there were processes in place to analyse the causes of these to reduce the likelihood of reoccurrence. People received their medicines as they had been prescribed and there were robust procedures in place for the safe management of medicines.

There were enough skilled and qualified staff to provide for people’s needs. Robust recruitment and selection processes were in place and the provider had taken steps to ensure that staff were suitable to work with the people who lived at the home. Staff received training to ensure that they had the necessary skills to care for the people who lived at the home and were supported by way of supervisions and appraisals. Nurses were supported to maintain and update their skills to maintain their registration.

People’s needs had been assessed when they moved into the home. They, their relatives and other healthcare professionals had been involved in determining their care needs and the way in which these were to be met. People’s consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met.

A range of activities were provided and people we spoke with reported they had enough to do. People were supported to have enough to eat and drink although feedback from people about the quality and choice of food was varied.

The provider had systems in place to monitor the quality of the service which identified areas for improvement and suggested remedial actions to be taken. Staff were able to contribute to the development of the service through team meetings and understood the visions and values of the service. People and their relatives had opportunities to share their views and make suggestions about how the service could be improved. Complaints about the service were managed appropriately and in line with the provider’s policy.

We found that people were provided with a choice of nutritious food and hydration in sufficient quantities to meet their needs. People were complimentary about the food provided. One person said, "The food is excellent. I have not had a single bad meal since being here. We are given choices ." Another person said, "The food here is like any restaurant, could be not so good but overall it is good."

There were systems in place to ensure that people's medicines were managed and administered safely. We noted that the practice in place to ensure handwritten entries on the medication administration record (MAR) sheets were countersigned by a second staff member was not consistently followed.

The service had suitable arrangements in place to ensure equipment used to promote people's safety was appropriately maintained. There was an effective recruitment procedure to ensure staff were recruited appropriately. We found that the service regularly assessed and monitored the quality of care that people received.

There was a relaxed atmosphere in the home, and we observed that people were offered support at a level which encouraged independence and assured their individual needs were met. The staff were friendly and courteous in their approach to people and interacted confidently with them. One person said, "I'm very happy, they're fantastic, it's a wonderful atmosphere. I'm treated very well."

We noted that people were encouraged to express their views and were involved in planning their care, making decisions about their support and treatment, and how they spent their time. Within the care files we saw people had signed their care plans to confirm their involvement and agreement.

Staff told us they felt well supported, and records we looked at showed us that staff development and conduct was monitored by the registered manager through a supervision and appraisal process. However there had been a recent lapse in this process which the new home manager was addressing at the time of this inspection.

The provider had clear quality monitoring systems in place however they were not always being used effectively to drive improvements in this home.