Hollin Knowle Residential Care Home

This inspection was unannounced and carried out by two inspectors. There were 16 people living at service and receiving personal care.

There was a registered manager for the service at the time of this inspection, who is also one of the registered partners [care providers]. A registered manager is a person who has registered with the Care Quality Commission. They are responsible for the day to day management of the regulated activity of personal care at the service. Like providers, as a registered person they have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in February 2017 we rated the service as Requires Improvement. At that time the provider had made improvements to ensure people’s medicines were safely managed. However, staffing arrangements were not always sufficient to ensure timely care or adequate environmental cleanliness, to protect people from the risk of an acquired health infection. We also found the provider did not operate effective management systems to inform and ensure related service improvements when required. These were respective breaches of Regulations18 and 17 of the HSCA (Regulated Activities Regulations) 2014. Following that inspection, the provider told us what actions they were taking to address this.

At this inspection we found the required action taken by the provider was to rectify the breaches. Resulting care and service improvements were made to an overall standard of Good. However, further improvement was needed in relation to how the service is led. As the provider now needs to demonstrate their ability to proactively and consistently ensure sustained, timely and continued service improvement.

Overall, people, relatives and staff felt people received safe care. Revised staffing, safe recruitment and environmental cleanliness and hygiene measures, were either made or in progress, to ensure this.

The provider had responded to local authority concerns to ensure people’s safety at the service, following an increase in people’s falls there. Revised falls prevention, reduction and management strategies were introduced in consultation with relevant external health professionals, to ensure people’s safety at the service.

Staff supported people safely when they provided care. Risks to people’s safety associated with their health conditions, medicines needs or, any care equipment used, were assessed before people received care, safely accounted for and regularly reviewed. People’s medicines were safely managed.

Environmental upgrade, adaptations and repairs were either made or in progress. Emergency contingency planning and related risk management arrangements helped to ensure people’s safety.

People received effective care. People and relatives were happy with the care and meals provided.

Overall, people were supported to maintain or improve their health in consultation with relevant external health professionals.

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. Staff were trained and supported to help ensure this.

Action was taken when required, via relevant health professionals, to review and inform people’s care in their best interests. Important care and medicines information was shared with relevant external care providers, in the event of any transfer of people’s care from the service.

People and relatives were happy with the care and had good relationships with staff. Staff understood and followed people’s care and daily living choices; and promoted people’s dignity, independence and rights when they provided care.

People received individualised, timely care from staff who knew how to communicate with them in the way they understood. People were supported to engage in home and community life and with family as they chose.

The provider complied with the Accessible Information Standard (AIS). They had begun to introduce and make sure people with a disability or sensory impairment were provided with care and service information in a way they could understand.

People and relatives were informed to make a complaint and the provider regularly sought their views about the service. Feedback and findings obtained from this were used to inform and make care changes or improvements.

Staff understood their role and responsibilities for people’s care. The providers operational procedures; communication and reporting systems helped to ensure this.

Management were visible, accessible and worked closely with people, relatives and external care partners. A range of service improvements made, or in progress at this inspection, helped to better ensure the safety, quality and timeliness of people’s care, to their benefit.

Records relating to management of the service, people’s care and staff employed were often accurately maintained and they were securely stored and handled. People and visitors at the service were informed about the latest CQC inspection report.

Hollin Knowle Residential Care Home provides nursing and personal care for up to 19 older people, including some people living with dementia. At the time of our inspection, there were 19 people receiving care at the service. There was a registered manager for the service at the time of this inspection. This is a person who has registered with the Care Quality Commission. They are responsible for the day to day management of the regulated activity of personal care at the service. Like providers, as a registered person they have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in September 2015 we found that people were not fully protected from known risks to their safety associated with the unsafe management of medicines. This was because the provider did not ensure people’s medicines were being consistently given as prescribed. This was a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following our inspection the registered provider told us about their action to address this and ensure people’s safety. At this inspection we found the required improvements were made. This meant people’s medicines were safely managed and consistently given to them as prescribed. Related staff training and management procedures helped to ensure this.

Staffing levels and skill mix were not sufficient to consistently ensure environmental cleanliness or people’s timely care, individualised care. This also had an impact on people’s care as their known daily living choices, independence and lifestyle preferences were not being consistently upheld or met.

Staff were often visible, knew people well and prioritise their care to help ensure their individual safety. Staff understood and followed people’s care plans to help mitigate known risks to their safety associated with their health conditions, environment and equipment used for their care.

Recognised staff recruitment, incident reporting and safeguarding procedures were understood and followed by staff when required, which helped to protect people from the risk of harm or abuse.

Equipment used for people’s care was often checked and maintained to ensure safe use. Emergency planning arrangements helped to ensure people’s safety. Planned environmental and repairs and for outstanding equipment servicing required helped to further ensure this.

People’s health and nutritional care requirements were understood and followed by staff who supported people to maintain and improve their health. People accessed external health professionals when they needed to and staff followed their instructions for people’s care when required.

People were usually provided with care in line with the Mental Capacity Act 2004 (MCA); to obtain people’s consent or appropriate authorisation for their care. The provider did not regularly check whether staff understood or followed the MCA, resulting in significant delay for requesting relevant authorisation for one person’s care when required. Additional staff training subsequently provided helped to reduce the risk of this reoccurring.

People received safe but not always timely support to eat and drink People were supported to receive sufficient amounts of food and drink and to maintain a balanced diet. People mostly enjoyed their meals but were not well informed about meal choice, which some people felt were limited. Food temperatures were not always effectively maintained from serving meals to when people received them.

Staff mostly received the training and supervision they needed to provide people’s care. Overdue training updates were organised for staff where required, which helped to fully ensure this.

Staff were kind, caring and compassionate. They treated people with respect and ensured their dignity when they provided care. Staff knew people well and understood what was important to them for their care. People and their relatives were consulted and involved in relation to their care and daily living arrangements.

People’s environment, daily living arrangements and related care requirements were not always fully considered or acted on to optimise their independence, orientation, choice or control.

People were informed about how to complain. The provider regularly sought to obtain people’s views about their care but did not always act to make improvements from this. This meant people’s care was not always individualised or responsive to their assessed needs and expressed wishes.

The provider’s arrangements to regularly monitor the quality and safety of people’s care were not wholly effective. They were not always sufficient to identify improvements needed. Improvements identified were not always acted on to improve the quality of people’s care when required.

The provider was able to demonstrate how they regularly monitored many aspects of people’s care and how improvements from this were often made to help ensure people’s safety, health and wellbeing.

People, relatives and staff felt the registered manager was visible, accessible and mostly helpful and supportive, but did not always listen or act on what they said about care improvements needed.

Staff understood their roles and responsibilities for people’s care and were informed and supported to raise any concerns about people’s care and often to make improvements required.

Records for people’s care and the management and running of the service were accurately maintained and safely stored. The provider met with their legal obligations to tell us about important events that happened at the service when required.

We found two breaches 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 this report.

Is the service safe?

People told us they felt safe. Relatives we spoke with told us they trusted service staff and had not had any reason to raise concerns about the care and treatment provided. Staff understood how to recognise and report concerns they had about people's safety and understood the role of the local authority in investigating adult abuse.

We saw staff received training in adult safeguarding and the skills and knowledge required to ensure people's health and safety in areas such as moving and handling and first aid.

Staff recruitment was managed effectively ensuring that staff employed by the service were of good character and understood their responsibilities to ensure the welfare of the people they provided care for.

We looked at systems to ensure people's health and safety including cleaning schedules and the management of fire risk and evacuation. We saw that these issues were carefully monitored and reviewed on a regular basis.

The provider had no knowledge of their legal duty to refer people who might be at risk of receiving inappropriate care for independent assessment under a law called the Deprivation of Liberty Safeguards (DoLS).

We have asked the provider to tell us what they are going to do to ensure people's consent to care is effectively reviewed and they meet their legal requirements in relation to DoLS.

Is the service effective?

People we spoke with were happy with the service they received. One person told us, 'I've got a lovely room with a very comfortable bed.' People said they were well cared for and involved in planning the care and support they received. One person told us, 'I choose my own clothes' another said, 'I get anything I ask for.'

Assessments of need included the clearly stated needs and wishes of people who used the service. Staff told us about people's assessed needs and how they worked with people to meet these needs.

Plans of care and associated risk assessments were well written and reviewed regularly. Staff described good working relationships with doctors and community based nurses and we saw records that confirmed effective working to ensure people's care and treatment needs were addressed.

Relatives we spoke with said they were consulted appropriately by the manager and staff. They felt their relative's health and wellbeing benefitted from the care and support they received.

Systems to ensure that people or where appropriate their representatives consented to the care provided were in place but this consent was not effectively reviewed

Is the service caring?

We observed staff offering people respectful and patient support. One person told us the staff were, 'Very good and very kind people.' Another person described the care they received and said, 'Two carers help me in and out of bed [and are] very kind and gentle.'

Staff we spoke with had a good knowledge of the needs of the people as described in assessments and care plans. They spoke in a compassionate and caring way about people's experience of illness or disability.

The provider carried out a survey in early 2013 seeking the views of families and friends about the quality of the service. The provider did not have a system in place, however, to obtain the views of people who used the service about the quality of care, for example about organised activities or meals and the way they are provided. We have asked the provider to tell us what they are going to do to ensure people's involvement in developing and improving the service.

Is the service responsive?

The manager and staff told us about the extensive support they offered to ensure one person received the care they needed in relation to ill health. We saw from records that the staff worked effectively with a number of community health professionals to ensure this person received the help they needed at the time they needed it. The person concerned told us they were very happy with the care that had been provided. We saw records that confirmed the provider's care had ensured the person's needs were met.

Is the service well-led?

The service reviewed and evaluated a range of health and safety systems to ensure the care home was clean, well maintained and safe for people to live and work in. These audits included detailed cleaning and maintenance schedules which were routinely completed and up to date.

Systems to manage complaints and accidents and incidents that can impact on the wellbeing of people were not effective. Ineffective management of complaints and accident/incident recording meant the service was unable to effectively analyse and understand the nature of problems that occurred. This meant the service was not able to learn from incidents and manage risks effectively.

We have asked the provider to tell us how they are going to improve the management of complaints, accidents and incidents.

People we spoke with were positive about the service they received and about the staff. They told us, 'I need help from staff to get around. They're very good, they know what to do. They help me in the shower as well. They let me get on with what I can do by myself.', and, 'The meals are usually ok. There's always enough for me.'

We found that the provider had taken action to improve the service since our previous inspection. People's care records had been updated to include more detail of their needs and personal preferences. Staff had received relevant training to ensure they could safely care for people. The bathrooms were being refurbished and one was almost completed, meaning that people would have a choice of bathing facilities. Activities for people in the home were provided on most days. However, we found a lack of variety in the activities offered and little attempt to cater for people's individual needs and preferences.

We found that there were some gaps in staff training. Some staff were not up to date with important training, such as safeguarding vulnerable adults and first aid.

People told us that staff were available when needed. They said, 'They come when I press my alarm at night', and, 'They're always in here (lounge)'. The visitor told us they had noticed the increased staffing levels and said, 'It's made a difference ' staff are always around now and there's more activities going on'. Staff told us the increased staffing was, 'A great help to us', and, 'We have time to give proper care'.

We found that the provider had made appropriate changes to improve the service to people and to ensure compliance with the regulation. The provider had increased staffing during the day and had ensured that staff were up to date with required training.

We found that people's needs were assessed, but assessments were not always kept up to date and so did not reflect their changing needs. Care was not always planned or delivered in a way that met people's individual needs or ensured their safety and welfare.

People we spoke with told us that staff were usually available when needed. One person said, 'I use my bell at night and they come straightaway.' However, our observations and findings showed that there were not always sufficient staff to safeguard the health, safety and welfare of people using the service. We found that staff were not always suitably qualified, skilled and experienced to ensure that people were safe and their needs were met.

People and visitors we spoke with were positive about the staff. However, we found that staff did not always receive appropriate training, supervision and appraisal to enable them to care for people safely.

We found that the provider had taken appropriate action. The provider gave us information and evidence to show the changes they had made ensured their systems were more effective.