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Archived: Knyveton Hall Rest Home Requires improvement

Reports


Inspection carried out on 26 July 2018

During a routine inspection

This unannounced inspection took place on 26 July and 2 August 2018. Both days were unannounced. The aim of the inspection was to carry out a comprehensive review of the service and to follow up on the seven requirement notices that were issued at the previous inspection in November 2017.

Knyveton Hall is a 'care home'. People in care homes receive accommodation and nursing or 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 home is registered to accommodate a maximum of 39 people who require support with personal care. There were 28 people living in the home at the time of our inspection.

Accommodation is provided in individual bedrooms on the ground, first and second floors. Some rooms have ensuite facilities. There is a large lounge and a dining room on the ground floor.

The service was led by 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.

At the last inspection we identified that management systems in the service were not effective and this had resulted in seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to person centred care, acting in accordance with the Mental Capacity Act 2005, the management of risk and of medicines, receiving and acting on complaints, staff support and training, record keeping and good governance. Required notifications had also not always been submitted to CQC. The service was rated as inadequate in relation to the question: is the service safe? Rated as requires improvement with regard to the questions is it effective? Is it responsive? Is well led? And was rated good for is the service caring? At that inspection the service received a rating of requires improvement overall.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions is the service safe? Is the service effective? Is the service responsive? And is the service well led? to at least good. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our last inspection had been made.

The registered manager had taken ownership of the concerns and had employed a specialist care home consultant to support the work required to improve the service. At this inspection we found that improvements had been made in all areas, and that all except two of the regulations had been complied with. We found that there were still shortfalls in the management of medicines and auditing processes which had not identified the issues noted at this inspection. The registered manager gave us assurances that work to complete improvements was ongoing and agreed to keep us informed when outstanding actions were completed. This is the second time that the service has been rated as Requires Improvement overall. However, the registered manager has demonstrated that they are making and will continue to make the required improvements and this is recognised in the improved ratings for three of the four areas which were previously rated inadequate or requires improvement. You can see what action we told the provider to take at the back of the full version of this report.

All the people we spoke with told us they felt safe and well cared for. Visitors, staff and health professionals confirmed that they had observed improvements in the service. We received only positive comments about Knyveton Hall throughout our inspection.

People told us their care and support needs were met and that the staff were kind, caring and respe

Inspection carried out on 10 October 2017

During a routine inspection

This comprehensive inspection took place on 10 October and 9, 16 and 20 November 2017. The first day and second days were unannounced.

This inspection was brought forward from the planned date because we received information of concern from whistle-blowers and safeguarding alerts from the local safeguarding authority. At our last inspection in September 2016 we found the service was running well and rated it as good.

Knyveton Hall is a 'care home'. People in care homes receive accommodation and nursing or 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 home is registered to accommodate a maximum of 39 people who require support with personal care. There were 33 people living in the home at the time of our inspection.

Accommodation is provided in individual bedrooms on the ground, first and second floors. Some rooms have ensuite facilities. There is a large lounge and a dining room on the ground floor.

The service was led by 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.

The registered manager was supported by a deputy manager. Responsibility for many aspects of the day to day management and running of the home had been delegated to them by the registered manager.

All of the people we spoke with, and visitors, told us they felt safe and well cared for. We received only positive comments about Knyveton Hall throughout our inspection. However, at this inspection we breaches of seven of the regulations.

People told us that their care and support needs were met and that staff were kind, caring and respectful. Staff spoke knowledgeably about how people liked their care and support to be given. However, care plans and risk assessments did not cover all aspects of a person's health and care needs and were poorly organised, which meant it was difficult to establish which care plans were current.

There were a number of hazards around the home including loose carpets, unsafe storage of chemicals and inadequate maintenance of the fire prevention systems, which meant that action to identify and mitigate risks, had not been taken. The provider has since confirmed that action has been taken to address all of these areas.

People were not protected against the risks associated with the unsafe management and use of medicines. Care plans and medicine records lacked detailed information and guidance for staff and errors were not identified through the audit process that was in place. People’s rights were not always protected because staff had not acted in accordance with the Mental Capacity Act 2005.

Staff were not receiving regular and effective supervision, training and support. Most of the people we spoke with told us they had confidence in the staff and felt that they had the knowledge and skills to meet their needs. However, not all areas of essential training for staff had been provided and refresher training was overdue in the areas of training that staff had completed. In addition, where people in the home were living with specific health conditions, training to ensure that these were understood and staff knew how to meet these needs had not been provided.

Staff ensured people’s privacy and dignity was protected. People received personalised care from staff who were responsive to their needs and knew them well. Staff created a relaxed, friendly atmosphere in the home. People had access to a range of activities that they were encouraged to take part in.

Information about making a complaint was displayed in the home and was also included in the information that was given to peopl

Inspection carried out on 12 July 2017

During an inspection to make sure that the improvements required had been made

This inspection was unannounced and took place on 12 July 2017. At the last inspection in September 2016 the service was not meeting the regulations and we made a requirement under Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the auditing of the controlled drugs register had failed to resolve controlled drugs recording errors. These included medicines returned to the pharmacist but still recorded as being held in the home and incorrect recording of amounts of medicines in stock. The ‘Is the service Safe?’ question was rated as ‘Requires improvement’.

At this inspection we found the service met the regulations because of the improvements made in the management of medicines. The ‘Is the service Safe?’ question is now rated as ‘Good’.

The overall rating for Knyveton Hall remains Good.

The service had a registered manager at the time of the inspection. 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.

There had been an improvement in medicines management.

An environmental risk assessment had been undertaken and action taken to make identified hazards safer.

No new members of staff had been recruited since the last inspection. At the previous inspection we found the service had followed robust procedures to make sure suitable people were employed.

Staff had been trained in safeguarding adults and were knowledgeable in this field.

Risk assessments had been completed to make sure care and support was delivered safely with action taken to minimise identified hazards.

Accidents and incidents were monitored to look for any trends where action could be taken to reduce likelihood of recurrence.

There were sufficient staff employed to meet the needs of people accommodated.

Inspection carried out on 1 September 2016

During a routine inspection

This was an unannounced comprehensive inspection that took place on 1 and 2 September 2016. At the last inspection completed in April 2015 the provider was compliant with the regulations and quality but we recommended some improvements.

Knyveton Lodge provides accommodation, care and nursing for up to 39 older people, some of whom were living with early stages of dementia in a homely environment. At the time of the inspection there were 35 people living at the home.

There was a registered manager at the home at the time of the inspection. 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.

People, relatives and staff were very positive about the standards of care provided at the home saying people were treated compassionately as individuals.

The staff were knowledgeable about people’s needs.

Staff had been trained in safeguarding adults and were aware of how to make safeguarding referrals.

Risk assessments had been completed to make sure that care and support was delivered safely with action taken to minimise identified hazards. Accidents and incidents were monitored to look for any trends where action could be taken to reduce chance of such accidents recurring.

There were sufficient staff employed at the home to meet the needs of people accommodated.

There were recruitment systems in place to make sure that suitable, qualified staff were employed at the home. The home had a longstanding, loyal staff team who had worked at the home for many years.

Medicines were ordered, stored, administered and disposed of safely but there was improvement required concerning the recording and management of controlled drugs.

The staff team were both knowledgeable and well trained and there were induction systems in place for new staff.

There were good communication systems in place to make sure that staff were kept up to date with any changes in people’s routines requirements.

Staff were supported through supervision sessions with a line manager and an annual performance review.

Staff and the registered manager were aware of the requirements of the Mental Capacity Act 2005 and acted in people’s best interest where people lacked capacity to consent. The home was compliant with the Deprivation of Liberty Safeguards with appropriate referrals being made to the local authority.

People were provided with a good standard of food, appropriate to their needs.

People’s care needs had been assessed and care plans put in place to inform staff of how to care for people. The plans were person centred and covered people’s overall needs. However, the plans we looked at in depth were not all up to date and some improvement was needed.

There was a programme of activities to keep people occupied and engaged.

There were complaint systems in place and people were aware of how to make a complaint.

Should people need to transfer to another service, systems were in place to make sure that important information would be passed on.

The home was well-led with a positive, open culture with staff.

There were systems in place to audit and monitor the quality of service provided to people.

Inspection carried out on 28 and 30 April 2015

During a routine inspection

This unannounced inspection was carried out on 28 and 30 April 2015.

Knyveton Hall Rest Home is registered to provide personal care for up to 39 people. Nursing care is not provided. 29 people were living at the home when we inspected.

There was a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

At the last inspection in December 2014 we issued five warning notices for breaches of regulations relating to: people’s consent to care and treatment, the assessment, planning and delivery of people’s care, management of people’s medicines, management of records and the assessment and monitoring of the quality of service provided. We also issued five compliance actions for other breaches of regulations. These related to; responding appropriately to allegations of abuse, protection of people from the risk of infection, people not always being supported to be able to eat and drink sufficient amounts to meet their needs, staff support and staff recruitment. The provider submitted an action plan which stated they would meet the legal requirements by 1 March 2015.

The management team had made improvements with respect to the overall safety of the service. Action had been taken to comply with fire safety regulations, issues identified by the Environmental Health Officer, covering of radiators that posed a burns risk to people living at the home and management of substances harmful to health.

Improvements had also been made with regards to the management of medicines in the home and care planning, making sure there was up to date information for staff so that they could meet people’s assessed needs.

Staff were knowledgeable about safeguarding adults, what constituted abuse and how to whistle blow. It was agreed that the safeguarding policy would be amended to include all required information.

No staff had been fully recruited since the last inspection; however, we saw that robust procedures were now being followed to make sure that suitably qualified and competent staff were recruited to work at the home.

The home maintained adequate staffing levels to meet people’s needs.

Improvements in cleanliness and infection control had been achieved through the contracting of cleaning to an external cleaning contactor.

The management team had made the service more effective in meeting people’s individual needs than on the last two previous inspections of the home.

Staff were better supported by management through regular supervision and training of the staff.

People’s nutritional needs were being met with people reporting that a good standard of food was provided. There was better management of fluid monitoring when people were at risk of not having enough to drink. People were weighed regularly and action taken if a person was losing weight.

The staff and management had a better understanding of the Mental Capacity Act 2005 and how to make sure that people who lacked capacity had decisions made on their behalf in their best interest. The management had made appropriate referrals for people who fell under the Deprivation of Liberties safeguards.

Records we looked at were up to date and accurate.

People reported that the staff were caring and respected people’s privacy and dignity. Each person had an up to date care plan in place that had been developed with the person concerned or their representative using a range of assessment tools.

People reported an improvement in the level and range of activities provided in the home. People’s spiritual needs were also being met.

The home had an accessible complaints procedure. No complaints had been raised about the quality of service since the last inspection.

People reported that staff were prompt in responding to call bells.

The home had a long serving management and staff team and had worked hard to effect changes and make the necessary improvements highlighted at the previous two inspections.

Audits, staff and resident’s meeting and quality assurance surveys were taking place to monitor the quality of service provided.

Inspection carried out on 01 December to 03 December 2014

During a routine inspection

This was an unannounced comprehensive inspection carried out on 1 and 2 and 3 December 2014. At the last inspection in August 2014 we found a breach of regulations relating to consent to care and treatment, the care and welfare of people, management of medicines, safety and suitability of premises and assessing and monitoring the quality of service and records.

Knyveton Hall Rest Home is registered to provide personal care for up to 39 people. Nursing care is not provided. There were 34 people living at the home when we inspected. There was a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

An action plan was received from the provider which stated they would meet the legal requirements relating to consent to care and treatment, management of medicines and assessing and monitoring the quality of service provision by 12 November 2014. The provider told us that they would meet the requirement relating to the care and welfare of people by 10 January 2015. The provider did not send us an action plan detailing when they would meet the legal requirements for records.

At this inspection we found there were shortfalls in a number of areas. We found that the provider had not made the necessary improvements following our last visit in August 2014. Improvements were needed to ensure the service kept people safe and their rights were protected. Although people’s needs were being assessed, their care plans lacked detail about the support they should receive. This meant people were at risk of receiving unsafe care. There were other failings in relation to care planning. The information in people’s care records was not always up to date and there was a risk that people’s plans did not reflect their current needs.

People’s medicines were not safely managed, stored and recorded. Staff did not have clear instructions when they needed to give people ‘as needed’ medicines. There were no pain assessment tools in place. This placed some people at risk of harm and not receiving the treatment they needed.

Some people, who needed support to eat and drink, did not get the help they needed so they could do this safely and receive the food and drink they needed to keep them well.

The provider did not always comply with the Mental Capacity Act 2005, which included how to assess people’s capacity to make specific decisions.

Policies about keeping people safe and reporting allegations of abuse were in place. However, these were generic and did not reflect local guidance. We found one instance where the safeguarding policy had not been followed. Staff training records indicated that most staff received training in how to protect people from abuse and report it should they suspect abuse had occurred.

Staff were not always recruited safely to make sure they were suitable to work with older people.

Some areas of the home had not been cleaned thoroughly. Infection prevention and control procedures were poor and this put people at risk.

Many of the staff had worked in the home for several years and this provided continuity of care for people at the home. People spoke positively about the kindness of staff and how they were treated.

Most staff treated people with dignity and respect. However we witnessed an incident where one member of staff did not. Staff knew people’s care needs and some personal information about them. We saw good relationships and interactions between most staff and people.

There was little organised activity taking place in the home. People’s need for social stimulation, occupation and activities were not consistently met.

People’s care and monitoring records were not properly maintained and we could not be sure they accurately reflected the care and support that people needed and was provided to people.

Staff did not have the right skills and knowledge to provide personalised care for people who had specialist needs such as epilepsy, diabetes and stoma care. This was because they did not have the right training, regular support and development sessions with their manager.

The systems and culture of the home did not ensure the service was well-led. This was because people were not encouraged to be involved in the home, and they were not regularly consulted. The quality assurance systems in place were not effective, and did not identify shortfalls in the service. Staff told us that there was a blame culture in the home and the management structure was unclear.

We have taken enforcement action against Knyveton Hall Rest Home to protect the health, safety and welfare of people using this service.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

Inspection carried out on 11, 12 August 2014

During a routine inspection

We carried out a responsive inspection of Knyveton Hall Rest Home because of concerns we had received about the care provided to people living at the home and staffing levels.

This was an unannounced inspection which was undertaken over the course of two days. The care manager assisted us throughout the inspection.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

There were 36 people living at Knyveton Hall Rest Home on the day of our inspection. We spoke with nine people, one relative, the care manager, three members of staff the district nurse and a GP.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Care was not always delivered to meet people's needs. Where a need was identified, a plan was not always in place to meet this need. One person was identified as being at high risk of skin breakdown. We saw their care plan stated that they required an air mattress to protect this person from skin breakdown. However, when we checked this person's bed, we found that there was no air mattress in place. This meant that care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. We found that some people living in the home had been prescribed creams. There were no care plans in place for people who required creams that set out where the creams were to be applied and how often. There were no records that showed that creams had been applied as prescribed.

During the inspection we found two wooden ramps, situated on the ground floor and first floor of the home. These were used to cover the stairs to enable carers to push people in wheelchairs up and down them. On closer examination of the ramps, we found that they were slippery, unstable and not purpose built. Following our inspection we raised our concerns with Bournemouth Borough Council safeguarding and health and safety team.

There were enough qualified, skilled and experienced staff to meet people's needs. We spoke with three members of staff during our visit who told us that they felt the home was appropriately staffed to enable them to provide good care to people living in the home. One member of staff told us "I have no concerns really, we work as a team."

Is the service effective?

Where people did not have the capacity to consent, the provider did not act in accordance with legal requirements. We found that where people had cognitive impairments associated with living with dementia, mental capacity assessments had not been completed. We looked at the care plan for one person with a diagnosis of Alzheimer's disease and found that mental capacity assessments and best interest decisions were not recorded. For example, we saw that the person had received a flu jab in the winter and they were having their medicines administered by staff. There was no capacity assessment in place for this person, nor was there a best interest decision recorded.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. No applications had been submitted; however, the care manager explained that following the recent Supreme Court ruling, they were in the process of preparing DoLS applications to submit to the local authority. The provider had a policy and relevant staff understood how an application should be made.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. Prior to our inspection concerns had been raised with CQC regarding one person’s pain relief medication being posted via untracked post to another care provider. We discussed this incident with the provider who confirmed this. This may have caused significant delay to the person receiving pain relief and there was an additional risk of the medicine becoming lost.

Is the service responsive?

We looked at the care plan for one person and saw that they were identified as at high risk of malnutrition. Their care plan stated "food and fluids monitored." However, there were no food monitoring charts in place for this person. They had not been weighed since the 2 May 2014 and their Malnutrition Universal Screening Tool (MUST) was incomplete. This meant that the provider could not be sure if the person was underweight to enable them to plan and deliver care in a way that was intended to ensure the person's safety and welfare. Another person was too frail to be weighed; we found that the provider had not considered any other methods such as measuring Mid-Upper Arm Circumference (MUAC) to ensure that the person was protected against the risks of inadequate nutrition.

Is the service caring?

We found the service was caring as people were treated with dignity and respect. We spoke with nine people who told us that they were happy with the service they received at the home. They told us they got on well with the staff, who respected their privacy and dignity. One person said "I find them very helpful. I don't have a problem with the staff at all." Another person told us "The girls are very good, excellent actually." A visitor told us that they felt their relative was treated with dignity and respect.

We observed positive interactions between staff and people living at the home during the inspection. We saw staff took time to listen to people when they needed support. We observed the lunchtime meal and saw that where people required assistance to eat, staff supported people in a relaxed and dignified manner.

Is the service well led?

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. This was because of the shortfalls we identified in the assessment, planning and delivery of care and support to people. In addition to this we identified serious shortfalls in the safety of the premises. This was because the provider had not assessed and managed the risks and safety of the premises.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. We looked at accident and incident records and found that there were details of what had occurred, actions taken if required and a periodic analysis to check for trends or triggers. For example, one person had been referred to the GP as they had been repeatedly falling in the home. We saw that as a result of this the person's medication had been changed to ensure their safety and welfare.

People were able to comment on the service provided. People told us that they had recently attended a resident meeting on the 01 July 2014 which included topics such as the summer fete and the importance of good hydration. We saw the minutes of the residents meeting which corroborated this.

Inspection carried out on 10, 15, 16 May 2013

During an inspection to make sure that the improvements required had been made

This was an unannounced inspection which was carried out as part of our schedule of inspections. We also monitored compliance with actions made at the last inspection in August 2012. Compliance actions related to infection control procedures, safety and suitability of the premises and recruitment procedures. We found that all actions had been complied with.

During our inspection spoke with four people living in the home, four members of staff and one of the providers.

People had their needs assessed and care plans were developed with people's involvement to ensure needs were met. When risks had been identified, such as falls, there was appropriate guidance and interventions in place to minimise this. People told us they felt safe in the home and their needs were met.

Significant improvements had been made in infection control procedures within the home. Specialist advice had been sought and acted upon. Actions plans had been implemented following an audit to minimise these risks. All staff had received refresher training and had had 'spot checks' on their practice to ensure they were competent in controlling infection.

A major decoration programme had been implemented, with the aim of completely redecorating and refurbishing areas of the home. The provider said they aimed to complete this over the next twelve months.

The provider had suitable arrangements in place to monitor the quality of the service provision and risks to people.

Inspection carried out on 14, 21 August 2012

During a routine inspection

We saw that people were able to make choices about what they did and how they spent their time. These included when they got up and what time they went to bed and what food they ate. People's liberties were not restricted and safeguards had been put in place if needed to make sure a person was safe when they were away from the home.

People's needs were met according with their plan of care. People were able to go out and risk assessments were in place to ensure they were kept safe. Health needs were met with the involvement of other health professionals if needed. Comments we received about food provided were that it was "good" and "there was plenty to eat." Meal times were relaxed and there were sufficient staff available to support people if needed.

There were appropriate safeguards in place to protect people from harm and staff were aware of how to recognise possible abuse and report it.

Relatives and staff we spoke with said that the building needed to be redecorated and refurbished. Poor maintenance meant that there was a potential risk of cross infection. Staff had suitable protective clothing to wear and demonstrated good practice. However, other equipment such as liquid soap and paper towels were not available to minimise risk.

Staff received training and development to carry out their role, however, recruitment guidance was not consistently followed.

Records related to the running of the service were kept securely and had been updated when needed.

Reports under our old system of regulation (including those from before CQC was created)