Archived: Knotty Ash Residential Home

Knotty Ash 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 service provides support to up to 35 people and there were 32 people living in the home on the day of the inspection, many of whom were living with dementia.

The service did not have a registered manager in post 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. The registered manager had left the service in November 2018. A new manager had been recruited and started in post a few days before this inspection.

At the last inspection in June 2018, the registered provider was found to be in breach of Regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because consent was not always gained in line with the Mental Capacity Act 2005, people's records were not always accurate or up to date, the environment was not always safely maintained and systems in place to monitor the quality and safety of the service were not effective. We asked the provider to complete an action plan to show what they would do to improve the key questions of safe and well-led to at least good. During this inspection, we looked to see if they had made the necessary improvements. On this inspection we found some small improvements had been made regarding the Mental Capacity Act 2005, but the provider remained in breach of some legal requirements.

At the last inspection the provider was in breach of regulations as the systems in place to monitor the quality and safety of the service were not effective. We found during this inspection, that they were still not effective. Quality assurance processes were not in place to review all areas of the service and those that had been completed did not always reflect what actions had been taken to address the issues. If more robust quality assurance processes had been in place and were being monitored closely, then the serious issues that were found during the inspection would have been identified earlier by the registered manager or the provider and dealt with.

The management team completed various quality audits including care plans, medicines, cleaning and health and safety. However, these audits had not proved effective at identifying issues and were not reviewed to ensure issues had been resolved.

Medicines were not always managed safely within the home, as they were not booked in and counted accurately, there were no guidelines in place for staff to administer medicines that were prescribed ‘as needed’, and there were no times recorded for the administration of medicines that needed to be given at specific times.

There was no clear system in place to oversee accidents and incidents. Although a log was maintained, no information was analysed to establish potential themes or trends. This meant it would be difficult for lessons to be learnt or for actions to be taken to prevent recurrence of some incidents.

Small improvements had been made in relation to the homes compliance with the Mental Capacity Act 2005 (MCA). We saw a care file which had appropriate mental capacity assessments completed, and evidence of best interest decisions being made. However, we found that staff had not been trained in MCA, and had limited knowledge of how this related to peoples care. We have made a recommendation about staff training on the Mental Capacity Act 2005.

Some peoples care records lacked detail. We saw some care files that contained detailed information, including peoples likes, dislikes and preferences regarding personal care and food. However, some care files contained very limited information. and had limited personal details in there. A lack of personal information makes it harder for staff to tailor care to suit that persons preferences and needs. We spoke to the manager and director about this and we were told that care files were currently being updated to make them more person centred.

People told us that staff treated them in a caring way and respected their privacy and supported them to maintain their dignity.

People told us they felt safe with the care provided by staff. Staff we spoke with understood their responsibility in relation to protecting people from the risk of harm. Staff told us they had received training that had helped them to understand and support people.

The home appeared clean and well maintained during the inspection. Staff had access to personal protective equipment such as gloves and aprons and bathrooms contained paper towels and liquid hand soap to help prevent the spread of infection.

Activities were available and we saw people joining in and enjoying singing and dancing during the inspection. We also observed lots of warm and caring interactions between staff and people who lived at the home throughout the inspection.

Our observations throughout the day showed that people were treated with dignity and respect. People received comfort when needed. Staff used their knowledge of people to engage them and help build positive relationships.

Policies set out that when a safeguarding incident occurred management needed to take appropriate action by referring to the relevant safeguarding agency. However, we found an incident had not been reported to us, as legally required.

Safe staff recruitment procedures were in place to protect people from receiving personal care from unsuitable staff.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The provider was in breach of the regulations surrounding safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

Knotty Ash is a ‘care home’. 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 service provides support to up to 35 people and there were 29 people living in the home on the day of the inspection, many of whom were living with dementia.

At the last inspection in December 2016, the registered provider was found to be in breach of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s confidential records were not always accurate, up to date or stored securely, the environment was not always safely maintained and systems in place to monitor the quality and safety of the service were not effective. We asked the provider to complete an action plan to show what they would do to improve the key questions of safe and well-led to at least good. During this inspection, we looked to see if they had made the necessary improvements.

At the last inspection the provider was in breach of Regulations as the systems in place to monitor the quality and safety of the service were not effective. We found during this inspection, that they were still not effective. Quality assurance processes were not in place to review all areas of the service and those that had been completed did not always reflect what actions had been taken to address the issues. If more robust quality assurance processes had been in place and were being monitored closely, then the serious issues that were found during the inspection would have been identified earlier by the registered manager or the provider and dealt with.

Following the last inspection, the provider submitted an action plan to inform us of what they would do to improve the service based on the concerns identified. We found that they had not evidenced all of the things they told us they would do.

CQC had not been notified of all events and incidents that occurred in the home in accordance with our statutory requirements. Records showed that a number of incidents had taken place that had been referred to the local safeguarding team, however CQC had not been informed.

We found that risk to people was not always well managed. When risks such as weight loss were identified, we found that there were not always clear records to show how the risk had been addressed. Care plans were not in place to cover all of people’s needs. This meant staff did not have clear guidance on people’s care needs or how to meet them.

Medicines were not always managed safely within the home as they were not booked in accurately, people’s allergies were not recorded on medicine charts and directions for administration were not always clearly recorded by staff. We found medicines were not always administered as they had been prescribed.

We found serious concerns with the care plans we observed as they did not reflect people’s current needs or their individual preferences regarding their care and treatment. Care plans were reviewed regularly but not always updated when people’s needs changed and planned care was not always recorded to show it had been provided.

When able, records showed that people provided consent to their care. However, consent was not always gained in line with the principles of the Mental Capacity Act 2005 and best interest decisions were not clearly recorded.

There was no clear system in place to oversee accidents and incidents as although a log was maintained, no information was analysed to establish potential themes or trends. This meant it would be difficult for lessons to be learnt or for actions to be taken to prevent recurrence of some incidents.

Deprivation of Liberty Safeguards applications had been made for people appropriately, however, the outcome of these applications was not always clearly recorded within people’s care files.

A registered manager was in post and feedback regarding the management of the service was positive. 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 told us they felt safe living in Knotty Ash. We saw that there were sufficient numbers of safely recruited staff on duty to meet people’s needs in a timely way. Staff had completed safeguarding training and we saw that safeguarding referrals had been made to the Local Authority appropriately. Systems were in place to help ensure the building and equipment was safely maintained.

The home appeared clean and well maintained during the inspection. Staff had access to personal protective equipment such as gloves and aprons and bathrooms contained paper towels and liquid hand soap to help prevent the spread of infection.

Staff told us they felt well supported and received an induction, an annual appraisal and regular supervision. Regular training was also available to support staff knowledge.

Staff were aware of people’s dietary needs and preferences. People had a choice of meals and we saw that people were offered drinks and snacks throughout the day.

The home had been adapted to meet the needs of people living there and help to maintain people’s safety and independence.

People living in the home spoke very highly of the staff who supported them and told us they were treated with respect and relatives were also very happy about the care provided. We observed people’s dignity and privacy being respected by staff during the inspection. We saw many examples of warm, positive interactions between staff who worked in the home and the people who lived there.

Equipment was in use within the home when people needed it, to help maximise their independence and we saw staff encourage people to do as much for themselves as they could.

We saw friends and relatives visiting the home during the inspection and they told us they could visit whenever they wanted to. When people had no friends or family to support them, details of local advocacy services were available.

Activities were available and we saw people joining in and enjoying singing and dancing during the inspection.

A system was in place to manage complaints and we saw that they had been dealt with appropriately.

Ratings from the last inspection were displayed within the home as required.

You can see what action we told the provider to take at the back of the full version of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The home did not have a registered manager at the time of the inspection visit. 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. Shortly after our inspection visit the manager was registered with CCQ.

We found breaches of regulations relating to the premises being safe to use, record keeping and systems for assessing and improving the quality of the service provided. You can see what action we told the provider to take at the back of the full version of the report.

We found that records were not consistently managed well. This included records not being stored confidentially. Some records were out of date, not available or inaccurate. The provider was open and honest with us about record keeping and management within the home.

Some systems were in place for auditing the quality of the service however these were not always effective. Audit systems had not been in place or robust enough to identify issues we identified during the inspection. This included issues with records relating to medication, recruitment and assessments. It also included issues relating to the safety of the building.

People received their medication as prescribed and staff had a good understanding of medication people were receiving. However records relating to medication were not always up to date.

Applications for Deprivation of Liberty Safeguards had been completed for people who needed them. The manager had a good understanding of the Mental Capacity Act 2005 and how to apply it. However assessments of people’s mental capacity were not always correctly completed and the manager was unaware of this.

Sufficient staff worked at the home to meet people’s care needs. Staff had received training to help them carry out their role safely and well.

People felt safe living at Knotty Ash and staff knew how to report and manage any safeguarding concerns that arose.

People liked the meals and were offered nutritious homemade meals daily. People could choose where and when they ate their meal and were regularly offered snacks and drinks. Mealtimes were sociable and unrushed.

Staff had built good relationships with people living at the home and people liked and trusted them. Staff took time to get to know people and to talk with them about their interests as well as meeting their health and personal care needs. A number of activities took place at the home that people could participate in.

Staff were responsive and provided the support people needed with their health and personal care

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 '

Is the service safe?

Staff had a good understanding of how to support people in a way that met their needs.

There were sufficient staff on duty to meet the needs of the people living at the home. This meant that people received the support they needed with their personal and health care needs.

Equipment at the home had been well maintained and serviced regularly to ensure it was safe to use.

Wooden door wedges were in use for propping open doors when people were in their bedroom. This is a possible fire risk. No risk assessments were in place for assessing the risks this posed for people.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place.

Care records were not up to date and accurate. This meant that staff did not have access to guidance on how to support people safely and well. It also meant that changes to the person's health care needs were not being monitored frequently and therefore any changes may not be noted and addressed.

Is the service effective?

Relatives told us that they had been happy with the care and support people had received at the home. Discussions with staff and our observations showed that staff knew people well and were responsive to their needs.

Staff had a good understanding of people's care needs and the support people needed. Discussions with staff and relatives showed that staff had worked with health care professionals to ensure the support people needed was in place.

Is the service caring?

People living at the home and their relatives told us they had found staff to be kind and caring. One person commented, 'They are nice, ordinary people.' Another person described staff as, 'Kind, friendly.'

Throughout our visit we observed staff regularly checking on people to ensure their care needs were being met. We also observed that staff took time to talk with people as well as meet their care needs.

Is the service responsive?

Staff had a good knowledge of people's health and care needs. Discussions with people living at the home, relatives and staff showed that where people's health had deteriorated staff had taken action. This included contacting health care professionals and following their advice.

Is the service well-led?

Health and safety checks had been carried out regularly to ensure the environment and equipment were safe to use.

A number of systems were in place to check the quality of the service provided. This included a meeting with relatives and people living at the home to obtain their views of the service.

We found systems for checking the quality of the service were not effective. They had failed to note and therefore address the risks associated with the use of door wedges when people were in their bedrooms. Systems had also failed to note that records and files had not been well maintained and were not up to date. This meant staff did to have written guidance on how to support people safely and well.

We found that there were sufficient numbers of qualified, skilled and experienced staff in order to safeguard the health, safety and welfare of people who used the service. People told us that since our last inspection staffing ratios had increased and this had improved the quality of the care and support people received. One person told us, "If I have a problem the staff respond quickly."

We reviewed the records held by the provider and found that there had been some improvements since our last inspection. However, we found essential information missing from people's care plans which could lead to the risk of them receiving unsafe or inappropriate care and treatment. We also found that some policies and procedures had not been appropriately updated.

Relatives, staff and the people living at the home all commented that there had been recent improvements to the service provided. They told us that the addition of an activity coordinator had been beneficial in providing activities people had enjoyed. Relatives also commented that they felt communication between themselves and the home had improved. Several people including those living at the home told us that they found staffing levels had improved during the day. However people also told us that they thought staffing levels at night time were not always sufficient.

We found that people had been consulted and involved in planning their care and that people had been proved with the care and support they had needed. We also found that staff had a good understanding of how to meet people's individual needs and choices and how to communicate effectively with people.

Sufficient equipment was available at the home to support people with their mobility and care and welfare needs.

We found that records had not always been fully completed or updated and that some records lacked sufficient detail to provide guidance and or a clear audit trail.