Knowle Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service under a new provider. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Senior staff had not always been proactive in relation to the provider’s culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events.

The provider had systems in place to oversee accidents and incidents. This included reporting all events to the compliance team, which ensured that appropriate actions were taken and that incidents were reported to relevant authorities when required.

However, the provider identified that these processes had not always been followed consistently within the service. In response, the provider and the compliance team were working closely with the new management team to ensure that reporting procedures were followed correctly, accidents and incidents were managed effectively, and lessons learned were shared with staff to support ongoing improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Processes were in place to support safe admissions into the service. Pre-admission assessments had been completed although some lacked detail about the person’s history and where the person was living at the time of the assessment.

Referrals to community health and social care professionals were made as needed to support people’s care.

The electronic care records system included printable documents to be sent to medical staff if the person visited or was admitted to hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately.

Most people felt safe living at the service, and this was confirmed by their relatives. Staff knew what to do if they thought someone was unsafe. An issue identified during the inspection was recognised as a safeguarding event and managed appropriately including referral to the local authority safeguarding team.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Where people were subject to DoLS this was clear within their electronic care records. However, some staff were not fully able to explain the principles of DoLS and how they applied in practice. Despite this, records and observations indicated people were supported in line with their authorised DoLS, and this was being addressed through additional training and support for staff.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had been completed; however, the level of detail and quality was inconsistent. Information about risks to people's safety and wellbeing, along with measures to reduce those risks, was included, in detail in people’s care plans. However, we observed occasions where staff did not follow risk management detailed in care plans, particularly in relation to moving and handling practices. This was witnessed by the provider’s training manager who assured us training would be updated without delay. There was no evidence of people, or where appropriate, their relatives having been involved in the development of risk assessments.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

On the first day of assessment we found bed safety rails, used to prevent falls from people’s beds, did not have bumpers in place to prevent injury. The provider immediately arranged delivery and new bumpers were put in place on the same day. However, safety rails without bumpers had not been recognised as a safety issue prior the assessment. The only bath in the service was not working, a number of overhead lights in people’s bedrooms were not working and some bedroom furniture was broken. The provider put actions in place to address the issues we identified, and some had been resolved by the second day of the assessment.

The provider had made several environmental improvements since taking over the service and had plans in place to continue this programme. Fire safety had been prioritised along with the purchase of equipment to make sure all people were able to move up and down stairs safely.

The provider did not always make sure staff worked well together to provide safe care that met people’s individual needs.

Although there appeared to be enough staff available to meet people’s needs, deployment of staff and team working needed to be improved. For example, when the senior was administering medicines, other staff did not take over answering the telephone to allow them to concentrate.

The provider had recognised the need to review staffing arrangements. They identified that care staff required additional time to support people whose needs had changed and increased. They had also identified that current housekeeping arrangements were not sufficient to consistently maintain expected standards of cleanliness.

Systems for recruiting staff were safe and the provider’s training department were working with all staff to make sure they were up to date with required training.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

On the first day of our assessment, there were a number of cleanliness issues throughout the service. Unpleasant odours were present in communal areas and some bedrooms. Some chairs were heavily stained; some furniture was unclean and some carpets needed replacing when cleaning had not been successful. Wheelchairs, which were used communally, were not clean. Immediate action was taken to address cleanliness issues and the provider put systems in place to make sure standards were maintained. Carpets needing replacement had been identified on the provider’s refurbishment programme. Improvements were noted on our second day of assessment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Some good practices for managing medicines were followed but improvements were needed to make sure people always received their medicine as prescribed. We identified an issue with administration of Warfarin, a medicine used to thin blood and prevent clotting. Warfarin dosage is changed regularly following blood tests. On 3 occasions it appeared the wrong dosage of Warfarin had been administered. Immediate actions were taken to make sure the health of the person concerned was not affected and to prevent the error being repeated.

Records of application of patches to deliver medicine through the skin were usually good, however we noted 1 occasion when the same application site had been used within a 4-week period which was not in line with the manufacturer’s advice. Records of application of creams needed to be improved and a tube of out-of-date prescription toothpaste in a person’s room indicated it had not been used as prescribed. This was noted as a concern by the area manager.

Good systems were in place for administration of medicines that needed to be given at specific times and medicines that needed a gap of 4 hours between administration.