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Inspection carried out on 11 April 2019

During a routine inspection

About the service: The Knolls Care Centre is a Nursing home providing personal and nursing care to 49 people at the time of the inspection, some of whom were living with dementia. The service can provide care for up to 56 people.

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

Inspection carried out on 7 December 2017

During a routine inspection

We carried out an unannounced inspection on 07 December 2017. During our last inspection in February 2017 we rated the service as good. During this inspection the rating changed to requires improvement. The Knolls Care Centre (The Knolls) is a ‘care home with nursing’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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.

Inspection carried out on 8 February 2017

During a routine inspection

This inspection visit took place on 08 February 2017. The visit was unannounced. When we carried out the last comprehensive inspection in November 2015 we found the service was not meeting the expected standards in relation to the provision of sufficient staff to meet people’s needs safely and in notifying the Care Quality Commission (CQC) of significant events as required. At this inspection we found that improvements had been made and the service was now meeting these requirements.

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.

Inspection carried out on 10 November 2015

During a routine inspection

This inspection took place on 10 November 2015 and it was unannounced. When we inspected the service in November 2014 we had found the provider was not meeting all the legal requirements in the areas that we looked at. We had found that the registered person did not use people's views, comments and complaints to effectively monitor, evaluate or make improvements to the service provided. During this inspection we found that improvements had been made to quality assurance processes.

The service provides accommodation, support and nursing care for up to 56 people with a variety of social and physical needs. Some people may be living with dementia. The home had three units within it. One providing nursing care, another providing residential care and a 6 bed roomed rehabilitation unit where people can stay for up to six weeks. At the time of our inspection there were 47 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.

Staff understood their responsibilities with regards to safeguarding people and they had received effective training. Referrals to the local authority safeguarding team had been made appropriately when concerns had been raised.

People told us that there were insufficient members of staff on duty and they did not have their care needs met at their preferred time or their call bells answered in a timely manner. Staff were competent in their roles and felt supported with regular supervisions and appraisals had been completed. Robust recruitment procedures were in place.

It was not clear whether or not people had been involved in planning their care and deciding the way their care was provided. Each person had a care plan which reflected their preferences and included personalised risk assessments, but they lacked detail and there were inconsistencies within the records. People's health care needs were being met and they were assisted to receive support from healthcare professionals when required. Medicines were managed safely and audits completed.

Positive relationships had been formed between people and members of staff. Staff were kind and caring, and provided care in a respectful manner that maintained people’s dignity. Staff knew people’s needs and preferences and provided encouragement when supporting them. There were a wide range of activities available and people received relevant information.

People were not aware of the presence of the registered manager and there was a lack of overall strategic management of the home. People, their relatives and staff knew the senior staff they could raise concerns to. Quality assurance processes were in place and were used with a view to improve the service being provided.

During this inspection we found the service to be in breach of some of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 27 November 2014

During a routine inspection

We undertook an unannounced inspection of The knolls Care Home on 27 November 2014. The home provides accommodation, support and nursing care for up to 50 older people. At the time of our inspection there were 48 people living in the home, some of whom were living with dementia.

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.

The service was safe and risks to people were assessed and minimised.

There were appropriate numbers of suitably skilled and qualified staff on duty to meet people’s needs. Staff received on-going training and support and were aware of their responsibilities when providing care and support to people at the service.

Medication was administered by staff who had received training on the safe administration of medication and accurate medicine administration records were kept.

The manager and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS), but some assessments had not been appropriately completed.

Each person had a support plan in place detailing their needs and preferences. People were supported to access healthcare services as required .

People’s views were sought, but not always used effectively to make improvements to the quality of the service.

Audits were not used effectively to monitor the quality of the service because information about actions taken was not always recorded. Records were not always well organised, up to date or fit for purpose.

During this inspection we found the service to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 19 April 2013

During a routine inspection

During our visit to the service on 19 April 2013 we spoke with four people who used the service and five staff members.

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.

Inspection carried out on 10 December 2012

During a routine inspection

When we visited the The Knolls Care Home on 10 December 2012, we found that most people were very satisfied with the care and support they received. They told us they felt safe and well cared for, and the staff were friendly and supportive. One person said. "I'm looked after very well, everything is beautiful."

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.

Inspection carried out on 22 November 2011

During a routine inspection

During our visit to The Knolls Care Home on 01 November 2011 we spoke with people receiving care in the nursing unit, the rehabilitation unit, and the residential unit of the home.

People we spoke with said that they were well cared for and staff explained the care they were giving to them in advance of carrying it out. People in the rehabilitation unit told us that they had not been given much information about the home before they left the hospital, but once they arrived at The Knolls staff had explained the rehabilitation programme to them. We asked people if they were able to make decisions about how their care was provided; One person said, �I can get up when I want. I always have the option to have a lie in, but I usually like to be up between 8.30 and 9 o�clock in the morning�.

Everyone we spoke with was satisfied with their care. One person said of the staff, �They are all brilliant and look after us so well�. Another said, �The staff have really helped to build up my confidence and I can now do things for myself that I couldn�t do when I was in hospital�. People using the service to find out if they felt safe living at The Knolls. They told us that the staff were kind and appeared to know their job and understand people�s needs.

Everyone told us that they were satisfied with the communal areas and their individual accommodation. People told us that they were looking forward to having more communal space again when the redecoration was completed. We spoke to two sets of people who shared a bedroom and they all said that sharing did not cause them any problems. There were screens in each bedroom that could be used to protect an individuals privacy.