We carried out an unannounced comprehensive inspection on 4 and 19 July 2017.

Knappe Cross Care Centre provides care and accommodation for up to 42 older people. The home is a detached house set in its own beautiful grounds in the seaside town of Exmouth in the coastal area of East Devon. On the first day of the inspection there were 30 people staying at the service.

The service did not have a registered manager when we visited. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 had left the service the week before our inspection. They had submitted their application to the CQC to cancel their registration. A new manager had been appointed and had shadowed the registered manager for one week. They confirmed they would be completing their application with CQC to become the registered manager at the service. Although the manager had only been at the service for 7 working days, staff were very positive about their impact and said the staff morale had improved at the home. People and visitors said they had met the new manager and were also very positive about their approach. One person commented “Manager is getting involved, willing to see how things are done, taking the job seriously.”

The service was previously inspected in May and June 2016 when the service was rated as ‘Requires improvement’ overall with no breaches of regulations. The effectiveness and leadership at the service was rated as requiring improvement. This was because changes had been put into place at the service which had not been embedded and staff training and updates to ensure staff were competent and effective had not always been updated in a timely way. At this inspection, we found improvements had been made in these areas although further work was being undertaken to ensure all staff had received the provider’s mandatory training.

The new manager had identified gaps in staff training matrix and wasn’t assured staff had received all of the provider’s mandatory training. They had set up a training planner for the next year to ensure staff would receive the required training. Individual risks to people’s safety had been assessed and care plans written to show how these were being addressed. We found one person’s care plan was not fully updated to guide staff how to provide care when their needs had changed a few days before our visit due to an injury. This was reviewed promptly after we discussed it with the manager.

The manager said their first priority at the home was looking at wound care management. This was following an incident which had occurred at the home which had been reported to the local authority safeguarding which had been resolved. The CQC are working with the provider regarding this incident and whether there is any potential risk to others at the home.

People were supported to take part in some social activities. The provider was actively recruiting a new activity person. One member of staff undertook additional duties to do some one to one sessions with people. However there were still limited activities for people who remained in their rooms. After the inspection the manager told us they had arranged additional hours with a staff member to undertake more activities while they were recruiting. This was to ensure people were not at risk of social isolation.

Medicines were safely managed and procedures were in place to ensure people received their medicines as prescribed.

People were supported by staff who had the required recruitment checks in place. Staff received an induction and were knowledgeable about the signs of abuse and how to report concerns. Staff relationships with people were caring and supportive. They delive

We carried out an unannounced comprehensive inspection on 31 May and 2 June 2016. We brought forward this comprehensive inspection because we received concerns regarding people’s care and welfare at the service. The service was the subject of a whole home multiagency safeguarding investigation at the time of our inspection. These concerns related to poor pressure care management, poor communication and records not demonstrating that people’s care and welfare needs were always being met. At our inspection we found the provider had been responsive and taken action regarding the concerns identified. Improvements had been made and people’s needs were being met.

Knappe Cross Care Centre provides care and accommodation for up to 42 people. On the first day of the inspection there were 30 people staying at the service.

We carried out an unannounced comprehensive inspection of this service on 16 and 20 July 2015. Two breaches of legal requirements were found. This was because people’s medicines were not being safely managed. People were not always receiving care that was person centred and reflected their personal preferences. At the last inspection, we asked the provider to take action to make improvements and this action has been completed.

The service is required to have 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 had changed their registration with The Care Quality Commission (CQC) to manage another service belonging to the provider. A new manager had been appointed and was in the process of completing their application with CQC to become the registered manager at the service. The manager had been at the service for five months at the time of our visit. Staff were positive about the manager and said they were approachable.

Medicines were safely managed. There had been improvements made for the monitoring of medicines stock at the service. Staff had recorded people’s allergies. Protocols had been put into place for people who had occasional use medicines. This meant they had met the previous requirement set by CQC.

Care plans were personalised and recognised people’s health, social and emotional needs. Care plans gave staff clear guidance about how to support people safely. They were personalised and people had been involved in their development. Plans were in place to involve people and appropriate relatives and friends in care plan reviews. Risk assessments were undertaken for people to ensure their health needs were identified. People were involved in making decisions and planning their own care on a day to day basis. People were being asked daily if they required a bath or shower although many still chose not to have one. They were referred promptly to health care services when required and received on-going healthcare support. People’s views and suggestions were taken into account to improve the service.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA.

There were adequate staffing levels to meet people’s needs. People felt there were adequate staff levels but said sometimes staff response times to call bells was slow. The operations manager was taking action to resolve a technical problem with the call bells. They also said they would monitor the response times to call bells to check people’s needs were being met in a timely way.

People were supported by staff who had the required recruitment checks. Staff received an induction and were knowledgeable about the signs of abuse and how to repo

On the day of our inspection there were 26 people living at the home and receiving care from the service. We spoke with seven people who lived at the home, the deputy manager, a registered nurse, five support staff and five ancillary workers. We also spoke to people visiting the home. One person told us “The staff are so good, we feel very lucky to have mum here”.

We found that people’s consent had been obtained for care and treatment provided to them by the service. People were being given choice about their daily activities and treated with kindness and respect.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. There was a variety of healthy and nutritious food and drink available. Where people had special dietary requirements or needed support we saw staff met those needs and skilfully assisted people to enjoy their meals.

We saw that care workers had time to complete tasks. They were busy, well organised and were meeting people's needs. One person told us "they are always so busy, but nothing is too much trouble.

We looked at the quality assurance systems in place to monitor the quality of care delivered. We saw that the provider monitored the service and sought regular feedback.

This inspection was a follow up from an inspection undertaken on 12 February 2013 at which we found one area of non compliance. This was in relation to inadequate staffing levels. At this inspection we found that the home had made improvements.

There were 28 eight people living at the home on the day of the inspection. We spent time observing people. Observation was used to assess the interaction and engagement between staff and people living at the home. We talked with three people that lived at the home, one relative five staff, the manager and the operations manager. We looked at three care records.

People living at the home told us that they were happy living there and staff were very good. People told us that their care needs were well met in a timely way. Support staff told us that things had improved at the home in the past few months. One person said “It’s so much better now we have more staff and more time to care for people properly”.

We (Care Quality Commission) last visited Knappe Cross in December 2012. At that visit we found that Knappe Cross was not meeting one or more essential standards and that improvements were needed. During this inspection we looked to see if these improvements had been made and we found that they had. However one other area of concern was identified at this inspection with regard to staffing levels.

People that we spoke with were satisfied with the care being provided. One person told us “The staff are very good” People told us that staff supported and helped them when they needed assistance. However people also told us staff were “always busy” and were “always rushing”. During our visit we heard staff speaking with people in a respectful and caring way.

We saw people were supported well and that the home was working with other agencies. This ensured the support people received was as far as possible consistent across all agencies.

We looked at all the bedrooms throughout the home, the toilets and bathrooms and communal areas. All areas were clean. All equipment we saw was clean. However two bedrooms were malodorous.

Staffing levels were insufficient to adequately meet the needs of the people who lived at the home in a timely way. People told us that staff were very good but were “rushed”. They said they had to wait “ages” for call bells to be answered.

Staff told us that they had recently received updated training and supervision.

We spoke with six people that lived at the home, one of their relatives and three staff. People we spoke with said they were happy living at the home. One person said “the staff are very kind”. People who use the service were not fully involved in decisions made about their care and treatment.

We found that although people liked living at the home, some of their needs were not being met adequately. Not all care records were completed properly.

We looked around all areas of the home. We saw that some of the facilities were not clean.

People benefited from safe equipment that met their needs.

We found that mandatory staff training was out of date. Specific training in certain illnesses such as epilepsy and diabetes had not been undertaken which meant that staff did not have the skills to look after people properly.

Staff told us that they receive regular training to enable them to support people safely. They also told us that although they sometimes feel more staff are needed, in general there are enough staff available to safely meet people’s needs.

The manager told us about systems that are in place in order to check the quality of care provided at the home.

We carried out an unannounced comprehensive inspection on 16 and 20 July 2015. Knappe Cross care centre provides care and accommodation for up to 42 people. On the first day of the inspection there were 32 people staying at the service.

We last inspected the service in December 2013, at that inspection the service was meeting all of the regulations inspected.

There was 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. Everyone was positive about the registered manager and felt they were approachable, caring and led by example.

The service did not have safe systems in place to ensure people received their medicines safely. Staff had not ensured the medication administration record (MAR) reflected the medicines people were prescribed. People were put at risk because there were not clear systems to identify people’s allergies. It was not possible to ensure people had received their medicines because of a lack of a clear stock control.

People did not always receive care that was person centred and reflected their personal preferences. People were not always given the opportunity or made aware they could have a bath or shower. Some staff were task focused and did not always ensure they were undertaking tasks in a caring inclusive manner.

There were sufficient numbers of staff to care for people. Staff were seen to be busy and were meeting people’s needs in a reasonable timescale. The registered manager was keeping the staff levels at the service under review and had made changes to the staff levels when required..

The provider demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. They had made appropriate deprivation of liberties applications to the local authority and had taken best interest decisions in line with the MCA.

People were supported by staff who were appropriately recruited and were trained and had the skills and knowledge to meet their needs. Staff had received a full induction and were knowledgeable about the signs of abuse and how to report concerns.

People were supported to eat and drink enough and maintained a balanced diet. On the whole everyone was positive about the food at the service. Where there were concerns the registered manager was working to address these.

People were supported to take part in a range of social activities in the main communal areas. The

designated activity person spent quality time with people who wanted to stay in their rooms to prevent them from being socially isolated. People were kept informed of current events and activities by a monthly newsletter.

Risk assessments were undertaken for people to ensure their health needs were identified. Care plans reflected people’s needs and gave staff clear guidance about how to support them safely.

People were referred promptly to health care services when required and received on-going healthcare support.

The service kept the premises, services and equipment well maintained to ensure people’s safety. There were emergency plans in place to protect people in the event of a fire or emergency.

The provider actively sought the views of people, their relatives and staff through staff and residents meetings and questionnaires to continuously improve the service. There was a complaints procedure in place and the registered manager had responded to concerns appropriately.

We found two breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.