The inspection took place on 18 October 2018 and was unannounced.

The Knoll 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 are looked at during the inspection. The Knoll accommodates up to 29 older people in one adapted building, which included up to 5 people who were receiving short term support and assessment as they had just come out of hospital. At the time of the inspection 25 people were living at the service.

There was a registered manager in post who was also the provider. 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 last inspected in March 2016 and was rated Good overall. At this inspection, we found two breaches of Regulation, the service is now rated Requires Improvement.

The registered manager was present at the service on a regular basis, but they relied on a team of staff to run the service on a day to day basis. The registered manager did not have oversight of the quality of the service. Checks and audits had been completed, however, the staff completing them did not have the knowledge to know when there were shortfalls and what action to take. The registered manager had not checked the audits staff had completed and had not been aware of the shortfalls present in the service.

Potential risks to people’s health and welfare had been assessed but there was not always detailed guidance for staff to mitigate the risk. People’s care plans had been reviewed but they did not always reflect the care being given. Some care plans did not contain detailed guidance for staff about people’s choices and preferences.

Before people moved into the service, staff completed an assessment of the person’s clinical needs, using referral documents and telephone assessments from health professionals. They did not meet with the person to discuss their needs and check that the service could meet their goals, cultural and social needs.

Medicines were not managed safely. Staff had not received regular training updates, however, staff were observed working within the current guidance. Staff understood their responsibility to keep people safe, the registered manager reported any concerns to the local safeguarding authority.

Accidents and some incidents had been recorded and analysed, however, more detail was required about the action taken to reduce the risk of them happening again. Some areas of the service such as the laundry room were not clean.

Checks had been completed on the environment and equipment to keep people safe. Checks had been completed on fire equipment. Fire drills had been completed, however, staff names had not been recorded and the drills had not been reviewed to assess if any issues needed to be addressed. The Knoll had been adapted to meet people’s needs, however, some areas needed refurbishment.

Staff were recruited safely, there were enough staff on duty to meet people’s needs. Staff received appraisal and supervision to discuss their practice and development needs. People’s health was monitored and referred to health professionals when required. Staff followed the guidance from health professionals to maintain people’s health. People were supported to eat a balanced diet and lead as healthy a life as possible.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were supported to make decisions about their care and support. Staff supported people at the end of their lives.

People had access to

This inspection took place on 29 and 30 March 2016 and was unannounced.

The Knoll Nursing Home provides accommodation for 29 older people who require nursing or personal care. At the time of the inspection there were 27 people living at the service.

The service is run by a registered manager who was present during our 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. The registered manager is supported by deputy managers and a clinical lead, who leads the team of nursing staff across the three services run by the provider.

We last inspected this service on 23 and 24 April 2015 and breaches of legal requirements were found. After the inspection the provider wrote an action plan to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and confirmed that they now met legal requirements.

People told us that they felt safe living at the service. Staff understood how to protect people from the risk of abuse and the action they needed to take keep people safe. Staff were confident to whistle blow to the registered manager or other organisations if they had any concerns and were confident that the appropriate action would be taken.

Risks to people’s safety were identified, assessed and managed. Assessments identified people’s specific needs, and showed how risks could be minimised. When new risks had been identified the registered manager had taken action to prevent them from re-occurring. They had updated risk assessments and passed the information to staff so that people would be safe.

People received their medicines safely and when they needed them. People’s medicines were reviewed regularly by their doctor to make sure they were still suitable. Accidents and incidents were recorded, analysed and discussed with staff to reduce the risks of them happening again.

Recruitment processes were in place to check that staff were of good character. Information had been requested about staff’s employment history, including gaps in employment. However, a full employment history and reasons for any gaps in employment had not been obtained for all staff. We have made a recommendation about this. There was a training programme in place to make sure staff had the skills and knowledge to carry out their roles effectively. Refresher training was provided regularly. People were consistently supported by sufficient numbers of staff.

People were supported to have a healthy diet. Their dietary needs were monitored and appropriate referrals to health care professionals, such as dieticians, were made when required.

Before people decided to move into The Knoll their care and support needs were assessed by the registered manager to make sure the staff would be able to offer them the care that they needed. People told us that they were happy with the care and support they received. People received their care in the way that they preferred. Care plans contained information and guidance so staff knew how to provide people’s care and support. Staff were familiar with people’s life stories and were knowledgeable about people’s likes, dislikes, preferences and care needs.

People and their relatives were involved with the planning of their care. Care and support was planned and delivered in line with people’s individual care needs. People spoke positively about staff and told us they were supportive and caring. Privacy was respected and people were able to make choices about their day to day lives. Staff were respectful and caring when they were supporting people.

The registered manager and staff understood how the Men

Our inspection team was made up two inspectors and a specialist clinical advisor. We spoke with some of the people who used the service and their relatives, the manager, nursing staff and care staff. We observed the interactions between people and whilst they were being supported by staff with their daily activities. We used our observation tool and communication aids to help us talk to people who had communication difficulties. We considered our inspection findings to answer questions we always ask: 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. This summary is based on our observations during the inspection, discussions with people using the service, staff supporting people, relatives and the manager.

Is the service safe?

The service was safe. When people had accidents the most appropriate and safe action was taken to make sure they received the treatment they needed. There were systems in place to make sure that managers and staff learned from accidents and incidents, concerns, complaints, whistleblowing and investigations. This reduced the risks to people and helped the service continually improve. Practices in the service protected people using the service, staff and visitors from the risk of harm.

Assessments had been undertaken to ensure that people received safe and appropriate care. The relevant people were consulted with regard to people’s mental capacity and the deprivation of people’s liberty was taken into account.

People using the service had a care plan which detailed their care and support needs. We saw there was guidance for staff to follow to reduce risks and implement strategies to make sure people were as safe as possible.

Is the service effective?

The service was effective. Care was consistently planned and delivered in response to people’s changing needs. People’s health and care needs were assessed with them and /or their representatives. We found that care plans were regularly reviewed to reflect any changes in a person’s needs.

People who used the service told us that their care needs were met. One person said, “The staff work really hard, [manager] is a busy bee. They all do their best. I couldn’t do it.” Staff support was consistent and structured. A core staff team was used across the three services run by the provider. Staff had the knowledge, skills and competencies to carry out their role effectively and safely because staff were properly trained, supervised and appraised.

Is the service caring?

The service was caring. People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. People we spoke with said they felt staff respected their privacy and dignity and staff were polite and caring.

One person who used the service told us, “If you want anything the staff will get it for you. They are really good. It’s a good home.”

Is the service responsive?

The service was responsive. Staff and visitors with whom we spoke told us they felt they would be listened to if they raised any concerns.

People told us that they were happy with the service. It was clear from observations and from speaking with staff that they had a good understanding of the people's care and support needs.

We saw records to show that the service worked closely with health and social care professionals to maintain and improve people's health and well-being.

Is the service well-led?

The service was well led. There was a clear management structure in place and we saw that there were quality assurance processes in place. Staff told us they were clear about their roles and responsibilities and that they felt well supported by the management team.

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Not all the people living at The Knoll Nursing Home were able to talk to us directly to tell us about their experiences. We spent time with people and observed interactions between the people and the staff. We saw that staff were attentive and supported people to make choices. People looked comfortable and at ease in the home and with staff.

People who used the service and their relatives, told us that they liked the home and the staff were polite, respectful and caring. People said there were enough staff to support their needs and that they were able to call them if needed. Visitors said they were confident and satisfied with the service and were able to visit at any time. One relative said, “I visit every other day and [person] always looks well cared for.” One person using the service commented that the care was good, “I feel safe”. Another person said, “I like the food and there is plenty to eat”. We found that people's health needs were supported and the service worked closely with health and social care professionals to maintain and improve people's health and wellbeing. We found that some improvement needed to be made regarding care planning for end of life care as people sometimes went into hospital when it may have been better for them to stay in the home and be cared for.

People said they would prefer it if there was more to do in the home as they found the time went very slowly. An activities coordinator was employed and outside therapists visited the home to provide some activities but there were still long periods of time when people were unoccupied. There was only a small amount of interaction with the staff because they were always busy providing care for people although people said they did stop and have a chat sometimes. There were lots of visitors in and out of the home throughout the day.

There were thorough recruitment processes in the home to make sure the right staff were employed. Staff received training to give them the knowledge and skills to support people and staff we spoke to said they enjoyed their work.

People who used the service told us what it was like to live at this service and described how they were treated by staff and their involvement in making choices about their care.

People said that they were happy with the care and support they received and that their needs were being met in all areas. They said that the staff treated them with respect, listened to them and supported them to raise any concerns they had about their care. People told us that the service responded to their health needs quickly and that the manager talked to them regularly about their plan of care and any changes that may be needed.

Many comments received were complimentary of the service. One person said “They look after me well here. I have no concerns". Another said "They have all been very good here. I have recently moved in and I like it here". Other people were complimentary of the food and had no concerns re the quality of care.

People told us they liked the home. They said they were well.

Some people said they liked to go to bed early and get up early.

People said they had what they needed in their rooms. They said they were comfortable in the home.

Not all the people living in the home were able to tell us about their experiences so we observed the interactions between the people living in the home and the staff.

We saw staff treat people with kindness and respect. Staff took their time supporting people with their care and talked to them checking to make sure the person was in agreement.

We were able to talk with most people but not everyone was able to tell us about their lifestyle and how they preferred to be supported and cared for. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We spent some time with people using the service and observed their lifestyle and interactions with the staff and other visitors.

People who use the service understood the care and treatment choices available to them. People said staff always asked their permission and explained what they were doing when carrying out care and support. A person commented, "the home is good and they treat me well". Another person commented, "the care home was not unusual, but not outstanding either".

People said they were treated with respect. One person commented, "they ask you what you want to be called when you first come".

People told us, "It's good here, the staff are good and the food is good."

People said that they were given enough food. One person said, "the food is OK, but I do not get any choice" and another person said the food was, " …too ordinary, but I do not complain as I am too easy going". However, three other people commented that they did have a choice of what they ate. One person said, “I like the food and I always have two or three things to pick to eat”. Another person said, "Cook will make anything I want if I do not like the choice".

Some people said they would like more entertainment. One person said the home is ok "but it's the monotony, we just sit here all day, this is it."

People said they liked the staff. One person said when they rang the bell “they come fairly quickly, and most of the staff are very kind”.

This inspection took place on 23 and 24 April 2015, was unannounced and carried out by one inspector and an expert by experience. The expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

The Knoll provides accommodation, support and nursing care for up to 29 older people, some of whom were living with dementia. A registered manager was in post who was also the registered manager for the two other services owned by the organisation. 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.

Potential risks to people were identified but full guidance on how to safely manage the risks was not always available. This left people at risk of not receiving the support they needed to keep them as safe as possible.

Accidents and incidents were recorded but had not been summarised to identify if there were any patterns or if lessons could be learned to support people more effectively to ensure their safety.

There were policies and procedures in place which covered emergency events but there were no plans in place to help people to safely leave the building in an emergency such as a fire.

The registered manager and staff understood how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. The registered manager understood when an application should be made and was aware of the judicial review in March 2014 which widened and clarified the definition of a deprivation of liberty. DoLS applications to the supervisory body had been made in line with guidance; however, the provider had not submitted notifications of the DoLS applications and their outcomes to CQC.

People told us they felt safe living at the service. Staff knew how to protect people from the risk of abuse and how to report any concerns they may have. Staff had been trained in safeguarding adults, and discussions with them confirmed that they knew the action to take in the event of any suspicion of abuse. Staff were aware of the whistle blowing policy and were confident they could raise any concerns with the registered manager or outside agencies if necessary. People were supported to take their medicines safely.

Recruitment processes were in place to check that staff were of good character and there were sufficient numbers of staff to meet people’s needs. Staff received regular training and there was a training programme in place to make sure staff had the skills and knowledge to carry out their roles. New staff received an induction and had access to range of training courses.

People and relatives told us that there were not enough staff on duty. Over the last three months the provider could not provide evidence to show which staff had been on duty. During our inspection there were sufficient staff with the right skills, knowledge and competencies to meet people’s needs. Other than at lunchtime, staff were not rushed. Staff received regular supervision and a yearly appraisal to support them in their role.

People were provided with a choice of healthy food and drink which ensured that their nutritional needs were met. People’s physical health was monitored and people were supported to see healthcare professionals when they needed to.

The design and layout of the service was suitable for people’s needs. The building was adequately maintained although there were some areas of paintwork which were scuffed.

People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. Staff knew people well but some care plans did not record all the information, such as, life histories to ensure that staff had the relevant information to support people in the way that suited them best. People told us they knew about their care plans but not all care plans had evidence to confirm that people had been involved in planning their care or had agreed with the care being delivered. Staff were clear on how respect people’s privacy and to treat people with dignity and respect.

Staff were caring and compassionate. Staff treated people with kindness, encouraged their independence and responded to their needs.

Systems were in place to check the safety of the service but checks had not been completed on the quality of the care people received. People were asked for their feedback about the service, but the views of their relatives and health care professionals had not been sought to identify any areas to continuously improve the service.

People told us that they would like more activities. People spent a large amount of time sitting with a television on in the lounges.

People and relatives told us that they would raise concerns with the registered manager or staff if they had any issues. They felt confident to make a complaint and that it would be acted on.

There was a statement of quality on display in the service, which outlined the visions and values of the service such as compassionate care. Staff were aware of these values and demonstrated their understanding of how to achieve this by offering people choice, treating them with dignity and responding to their needs.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we have asked the provider to take at the end of this report.