Archived: Knowsley Manor Nursing Home

Knowsley Manor Nursing Home is a care home providing accommodation along with personal and nursing care in one purpose-built building, for up to 50 people. At the time of our inspection there were 36 people living in the home.

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

The home’s environment was unclean and unsafe. Infection prevention and control practices were inadequate and did not protect people from the risk of infections.

Risks to people’s safety and wellbeing was not effectively managed. The risk assessment process in place for assessing and reducing risks for people had not been effectively used for several months. This meant that people’s care plans were out of date, contradictory, did not contain accurate information and did not reflect the care they were receiving.

People were not receiving personal care in line with their care plans. Records showed that some people had not received a bath, shower or had their hair washed for a number of weeks.

There were not enough staff available to keep the home safe and meet people’s needs in a safe and timely manner. One staff member told us, “There is never enough staff. We run around like headless chickens.” One person’s relative told us, “The carers are fantastic; there is just not enough of them”.

People relatives told us that staff members had a kind and caring approach towards their family members; but described a staff team overstretched and under stress. One staff member told us, “Today we are one staff member down, but it is tight every day; so, it makes a big difference being one staff member down.”

People’s medication was not safely managed. There were significant gaps in the systems that the provider used to ensure the ongoing safety and quality of the service being provided for people. These systems had failed to pick up on and address the concerns highlighted during this inspection.

The provider had not promoted a positive culture that achieved good outcomes for people. A despondent culture that had lost sight of safe and appropriate care had been allowed to develop within the home. The home’s environment had been allowed to become unsafe and unpleasant for people to live in.

During our inspection the provider arranged for additional management support at the home; alongside a review of each person’s care and took steps to improve the home’s environment.

During the inspection process, we raised or a whole service safeguarding with the local authority regarding the safety of medication administration and further safeguarding alerts for six people about possible neglect.

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 requires improvement (published 27 September 2019).

You can read the report from our last inspection, by selecting the 'all reports' link for Knowsley Manor Nursing Home on our website at www.cqc.org.uk.

Why we inspected

The inspection was prompted in part due to concerns received about people not receiving safe and appropriate care, safe administration of medicines, infection control and staffing. A decision was made for us to inspect and we undertook a focused inspection to review the key questions of safe and well-led only. Please see full details in the individual sections of this full report.

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.

Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

During our inspection the provider took action to mitigate the risks identified.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches at this inspection in relation to infection prevention and control, safe environment, managing risks, sufficient numbers of staff and good governance of the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There were safe measures in place to prevent visitors from spreading infection. At the entrance visitors were required to provide evidence of a negative Lateral Flow Device (LDF) test and put on the required personal protective equipment (PPE). Family members told us they were kept up to date with safe visiting guidance and they felt safe when visiting their relatives.

Shielding and social distancing rules were complied with. Furniture in communal areas had been rearranged and gatherings such as staff meetings and handovers took place in large spaces with minimal staff present.

New admissions were carried out safely. Evidence of a negative Polymerase Chain Reaction (PCR) test result was required for people before they moved in and they were supported to isolate for 14 days from the day of admission.

Good stocks of the right standard of personal protective equipment (PPE) were maintained and PPE stations were located across the service. Staff received training around the safe use and disposal of PPE and they followed current guidance.

There were designated infection prevention control IPC leads and they shared good working practices and updates across the staff team. Staff were kept informed of current IPC and PPE procedures and there was information about them displayed around the service.

People, staff and visitors had access to regular testing and testing records were maintained.

Staff provided people with the support they needed to maintain regular contact with family and friends using technology.

About the service

Knowsley Manor Care Home accommodates up to 50 people who require personal and nursing care. At the time of the inspection there were 37 people using the service.

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

We have made a recommendation about the monitoring and management of risk. The safety of the environment and equipment was not monitored to ensure risks to people and others were identified and mitigated. Equipment used to help people with their mobility such as wheelchairs, stand aids and hoists were unclean, increasing the risk of the spread of infection. The equipment was cleaned after we raised it with staff. Floor signs were used to alert people and others of wet floors, however the risks associated with wet floors was not always monitored and managed.

People’s needs were assessed and planned for, however care records for three people did not fully reflect how some of their needs were to be met. Whilst we did not evidence any impact on people, this placed them at risk of receiving ineffective care and support. Following the inspection, the manager assured us that the records were updated.

Some people’s bedrooms and bedroom furniture were in a poor state of repair. Paint work was scuffed and stained, and some items of furniture was damaged. Following the inspection, the manager assured us that an ongoing programme of decoration was about to commence.

The had been a lack of consistency in the management of the service. The service did not have a manager registered with the Care Quality Commission. An interim manager and management support team were appointed at the service whilst the provider was actively recruiting for a permanent manager. The current manager is the third in post since the last inspection. Staff felt different managers had different ways of working and these inconsistencies had unsettled them.

The processes for monitoring the quality and safety of the service were not always fully effective. Checks had not identified dirty equipment which was being used to assist people with their mobility and that some people’s care records did not fully reflect their needs.

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 understood their responsibilities for keeping people safe and for reporting any health and safety concerns. Safe recruitment processes were followed, and staff received the training they needed for their role.

People were treated with kindness and compassion and their privacy and independence was respected. Staff recognised when people needed emotional support and comforted and reassured people. People received personal care in private and their personal records were kept secure.

Care was planned and delivered taking account of people’s personal choice and preference. Activities and social events were planned around people’s interests and hobbies, however family members felt people would benefit from more opportunities to access the community. The provider had a complaints procedure which was accessible to all. Family members were confident about complaining and felt they would be listened to. Complaints were used to improve the service.

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 July 2018). The service remains rated requires improvement.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

There is no registered manager working at the service. There was however a manager in post who was responsible for the day-to-day running of the service. The manager had applied to CQC to become 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.

We carried out this inspection on 10, 15 and 18 May 2018. The first day of the inspection was unannounced and the other two days were announced.

At the last inspection, in June 2016, the service was rated Good. At this inspection we found improvements were required in relation to safe and effective care for people.

Medication was managed safely overall. However, on the first day of inspection thickening powder prescribed to people to modify their fluids was left unattended in a dining room which was occupied by people. If ingested thickening powder can cause a person to choke. The powder was stored away safely on the other two days of inspection. All other medication was safely stored and administered to people and there were safe systems in place for the receipt, disposal and returning of medication to the supplying pharmacist. People were administered their medication on time by suitably trained staff.

Call alarm bells were in place around most part of the service, however there were two toilets and two bathrooms without one. This meant that there was no means for people to alert staff should they need to when using those rooms independently. The manager immediately contacted the relevant department within the organisation to arrange for call alarm bells to be fitted and this done by the end of our inspection. Cleaning schedules were in place and being followed. The environment was clean and hygienic and smelt pleasant throughout. Staff followed good infection prevention and control practices to minimise the risk of the spread of infection.

Care plans were in place for people’s assessed needs and they included directions for staff on how to meet them. This included the completion of charts to record the care given. Some people’s charts did not include information about their care needs and others did not reflect the care given. Staff assured us that people had received the right care and we did not evidence any impact on people. However, there was no guarantee that people had received the right care and support in line with their care plan.

People were offered a choice of food and drink which was prepared in line with their dietary needs which were well documented. However, meals were not always well presented. Each element of a pureed meal for one person was mixed together in a bowl making the meal look bland and unappetising. Bread was placed on the edge of soup bowls rather than people being provided with a side plate. In one instance the bread fell into a person's soup and they struggled to eat it.

The quality and safety of the service was assessed and monitored. The required checks had been carried out and improvements made in line with the registered providers quality assurance framework. However more regular checks were required to ensure records about people’s needs and the care given were accurately completed and maintained. More robust checks to ensure people’s safety were also required in relation to the storage of thickener, presentation of meals and accessibility to call bell alarms. The manager quickly addressed these issues, however consistent good practice is needed over time to ensure people always receive safe and effective care.

People, staff, family members and other visiting professionals reported positively about the manager and their management style.

The environment had undergone some refurbishment since the last inspection making it more attractive and comfortable for people. At the time of the inspection further improvements were underway. Although there was some signage around the service to help orientate people and items of stimulation for people living with dementia, further improvements were needed. The manager recognised this and prior to the inspection had put plans in place for the development of communal areas.

People were protected from abuse and harm because staff understood how to recognise and report safeguarding concerns. Staff knew about the registered providers whistleblowing procedure and were confident about using it should they need to. Risks to people’s safety were assessed and mitigated, this included risks associated with aspects of people’s care and the environment.

Staff were recruited safely. Applicants were subject to a range of pre- employment checks prior to an offer of employment being made. This included a check on their criminal background, previous work history, skills and qualifications. Sufficient numbers of appropriately skilled staff were available to meet the needs of people and keep them safe.

Staff received training and support for their role. New staff completed induction training which included learning about the expectations of their role and emergency procedures. New staff were enrolled onto the Care Certificate and all staff were provided with ongoing training relevant to their role and responsibilities and people’s needs. Staff told us they received a good level of support from the manager and other senior staff. Since being appointed the manager had met with each member of staff on a one to one basis as a way of getting to know them and their training and development needs.

The manager and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Staff provided care and support to people in line with the principles of the MCA. The manager worked alongside family members and relevant health and social care professionals to ensure decisions were made in people’s best interests when this was required. Applications for DoLS authorisations had been made to the local authority appropriately. Expiry dates of DoLS were monitored to ensure they remained effective.

People’s healthcare needs were well documented. People received the care and support they needed with their healthcare and appropriate referrals were made when required to external healthcare professions. Family members were kept informed of any changes to their relative’s health and of any healthcare appointments made.

Staff were kind caring and respectful towards people and saw many examples of this. Staff were patient and sensitive in their approach, they comforted and reassured people with good outcomes for them. Where people were unable to tell us about their experiences we observed they were comfortable, relaxed and at ease with staff.

People were provided with opportunities to take part in group and one to one activities. A profile was put together based on information shared about people’s life history, important relationships, hobbies and interests. This enabled staff to plan meaningful activities for people and engage people in conversations of interest.

Knowsley Manor Nursing Home accommodates up to 48 people who require personal and nursing care. The service is situated close to Knowsley village. There were 47 people living at the service at the time of this inspection.

The service has a registered manager who was registered with the Care Quality Commission in December 2014. 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 last inspection of the service was carried out in July 2014 and we found that the service was meeting all the regulations that were assessed.

We have made a recommendation about monitoring the quality of the service. Checks were carried out at various intervals on things such as people’s care records, medication, the environment and infection control practices. However some checks on the cleanliness of the environment were not always effective. Some parts of the service people occupied and equipment used to help people with their mobility was unclean which increased the risk of the spread of infection.

The registered provider had a recruitment and selection policy which described a safe and fair procedure for employing new staff. Applicant’s suitability to work at the service was assessed based on information which they were required to provide. This included details about their previous employment history, skills and experience. In addition they underwent a series of pre-employment checks on their character before they started work at the service.

People were protected from avoidable harm and potential abuse because the registered provider had taken steps to minimise the risk of abuse. Clear procedures for preventing abuse and for responding to an allegation of abuse were in place. Staff were confident about recognising and reporting actual or suspected abuse and relevant staff were aware of their responsibilities to report abuse to relevant agencies.

There were safe systems in place for managing people's medicines. Medication was stored safety in dedicated rooms which were clean and tidy. Each person had a medication administration record (MAR) and a medication information sheet detailing their prescribed medication and any instructions for use. People received their medication on time by staff who had received the appropriate training and were deemed competent to carry out this role. When required people had accessed healthcare professionals such as GPs and specialist nurses.

People told us they had plenty to eat and drink. People’s nutritional and hydration needs were appropriately assessed and planned for. People received the support they needed to eat and drink and those who required it, had their weight, food and fluid intake monitored. Appropriate referrals were made on behalf of people to dieticians and speech and language therapists when there were changes in people’s needs.

People’s needs were understood and met by the right amount of suitably skilled and qualified staff. We received no concerns about the staffing levels. Family members told us there were enough of the right staff on duty to meet their relative’s needs.

People’s care plans contained good information about how people’s needs were to be met. Care plans were reviewed regularly and they reflected people’s current and changing needs. Daily records showed that people’s needs were met in accordance to their wishes and preferences which were set out in their care plans.

The registered manager and staff had a good knowledge and understanding of the Mental Capacity Act (2005) and their roles and responsibilities linked to this. They worked relevant others to ensure decisions were made in people’s best interests when this was required.

People’s privacy, dignity and independence was respected and promoted. Staff approached people in a patient, kind and caring manner and people received personal care in private. Staff ensured people received care and support in accordance to their preferences and wishes. For example people were dressed how they liked to be.

Staff received training that helped them meet people’s needs. Training included topics such as safe people handling, safeguarding, infection control and dementia care. Staff said they received a good amount of training which they benefited from.

Information about how to make a complaint was made available to people, their family members and visitors. People and family members said they would not be afraid to make a complaint if they needed to and they told us that they were confident they their complaint would be listened to and acted upon.

People who used the service, their family members and staff said they thought the service was well managed. The registered manager and senior staff including nurses were all described as being approachable and very supportive. There was an open door policy operated at the service which enabled people to speak openly and in confidence to the management team.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found '

Is the service safe?

People said they felt safe living at the home and relatives of people who used the service told us they had no concerns about people's safety. Comments included, "Yes, very safe." 'Yes I can leave here knowing my mum is safe and in good hands.' And 'Definitely safe, I trust them.'

Staff had received the right training to safely meet people's needs.

Appropriate plans were in place to manage any risks to people's health, welfare and safety.

Policies and procedures were in place relating to the Mental Capacity Act and Deprivation of Liberty Safeguards and relevant staff understood when an application should be made, and how to submit one. This meant that people's rights would be safeguarded as required.

Is the service effective?

People's needs were assessed and planned for with their involvement or the involvement of their relatives.

Staff communicated effectively with people who used the service and people responded positively to staff.

Staff had been trained to an appropriate standard to enable them to meet the needs of the people who used the service.

Is the service caring?

Staff were polite, respectful and patient towards people who used the service and their relatives.

Staff spent time reassuring people who were anxious and people benefited from the support staff gave them.

Staff encouraged people's independence and as a result people who used the service regained daily living skills.

Is the service responsive?

Staff responded to any concerns they had about a person's health or wellbeing which resulted in people receiving appropriate care and support when they needed it.

People who used the service felt confident about sharing their views and opinions about the service and they said they were listened to.

Systems which were in place at the home ensured any improvements were identified and responded to quickly.

Is the service well-led?

The service worked well with other agencies and services to make sure people received the right care and support.

The service had quality assurance systems which help make sure the service made continuous improvements.

Staff told us they were clear about their roles and responsibilities and that they could approach the manager if they needed any support or advice regarding their work.

People who used the service and their relatives told us that they thought the home was well managed and that they felt able to express their views and opinions about the service.

An effective recruitment process was in place at Knowsley Manor which ensured all required safety checks were completed before new staff started work. Available staff training files were inspected and found to be up to date. Staff supervisions were held every other month and full appraisals were conducted on an annual basis. People we spoke with were happy their `comments and complaints would be listened to and acted on`. People using services were aware of the complaints procedure and the provider informed us that all `comments would be considered fully and responded to appropriately and resolved within an acceptable time-frame`.

We observed during our inspection that the people who used the service appeared happy and content living there. We found people were treated respectfully and given support to have their say in how they wanted to be helped and were supported to do the things they wanted to do.

The people who lived at Knowsley Manor Nursing Home were cared for by staff who were appropriately recruited, well trained and experienced at supporting them.

People told us and our observations found that people's immediate needs were well attended to. People were treated with care and consideration. However we observed that some staff were more focussed on completing tasks for people, rather than acknowledging and engaging with them.

We saw evidence of robust care planning that had been personalised and addressed specific individual needs.

We saw a complaints policy and information about how to make a complaint was available in communal areas.

We saw that there were appropriate systems in place to monitor the quality of care that people received at the home.