Knappe Cross Care Centre

Knappe Cross Care Centre provides personal and nursing care to 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. At the time of our inspection there were 35 people using the service.

People’s experience of using this service and what we found

People were at risk because systems to monitor their well-being were not fully effective, for example the increased monitoring of people at risk due to constipation. In addition, staff were not always proactive in responding to and addressing risks in a timely way.

Medicines were not always managed safely, or in line with the providers medication policy. Risk assessments had not been completed regarding flammable paraffin-based creams; guidance had not been sought from a pharmacist about the effectiveness of crushed medicines given in yogurt; and staff were not consistently following systems for ordering, receiving and storing medicines.

These issues had not been identified by the providers governance systems which meant they were not fully effective. Action previously taken to address concerns about staff practice had not always led to improvements, for example related to medicines administration and recording.

The management team promoted a culture of openness and honesty. They were open and transparent during the inspection and took immediate action in response to concerns raised. This included seeking advice from external health professionals; ensuring staff were aware of the importance of monitoring and recording and arranging relevant training. Improvements were also made to monitoring systems.

The manager had been registered with the CQC for 3 weeks at the time of the inspection. They were being mentored by the operations manager who had previously managed the service. They told us they were well supported by the provider and felt safe and comfortable.

Overall, people and relatives spoke highly of the quality and safety of the service. Comments included, “They do everything to accommodate both of us. They support us with telephone calls morning and afternoon, and when I visit twice a week for a couple of hours. Completely brilliant. They said I am family as well” and, “I have no concerns about [family members’] safety. She has often said that they are good and that she's happy there.”

Staff told us they felt valued and happy working at the service. They felt well supported and were passionate about their role.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 13 September 2017).

Why we inspected

We received concerns in relation to the quality and safety of the support provided. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Knappe Cross Care Centre on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the assessment and mitigation of risks; the safe management of medicines and the effectiveness of governance processes. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The staff were following infection prevention and control guidance to help people to stay safe. The home was a very large, spacious building which enabled people to remain isolated safely in their rooms and staff to work safely. There had also been new staff break out areas created with allocated break times to promote social distancing. Staff knew people well and knew how to support them. The registered manager was working with the Clinical Commissioning Group (CCG) and local authority to ensure staffing levels remained satisfactory. Shifts were covered and people’s needs were being met. Domestic shifts had been covered by the maintenance team and the home was very clean and fresh with no odours. There was a small laundry which was clean. We advised that the laundry coming in was not allowed to build up and to ensure the clinical bags it was in remained intact. It had been difficult to maintain as much social engagement with people during their isolation with the one activity co-ordinator. However, the deputy manager was ensuring social engagement and wellbeing support was being recorded separately to monitor how people were feeling. The communal areas were not being used at this time.

There was enough managerial support to ensure there were enough staff to enable good governance, and staff available to give medicines safely. Agency staff had been used from the local authority to cover some shifts and recruitment was ongoing with some staff already in place to start employment when their checks were completed.

Staff were allocated to support named people to minimise cross contamination. Those people living with dementia were supported safely and there had been no issues with people independently mobilising outside of their rooms. The deputy manager was ensuring that people had every comfort available in their rooms and regular reassurance.

There were clear risk assessments and staff were following the correct procedures. For example, staff were not car sharing and were social distancing, including for staff breaks. Staff were also ensuring they were following safety guidelines in their home lives to further protect the people they supported. The management team were formally confirming that staff were not working elsewhere or car sharing. The provider was not accepting any new admissions at this time but were aware of the correct admission processes. When people from the home were discharged from hospital, they were following the correct procedures as well as ensuring they had the staff capacity to care for them safely before accepting the discharge.

The provider had provided training to ensure staff knew how to keep people safe during the COVID-19 pandemic. There were posters and guidance accessible at the service. The registered manager and senior staff ensured staff understood why every measure was in place and there were regular updates and reminders including during daily handovers.

There was a good stock of the correct PPE and staff knew what to do. Each floor had plenty of PPE stations and staff knew to change masks if they were touched or soiled, and otherwise used them sessionally. Each room had separate laundry and waste bins. Staff were a close-knit group and were well supported. The provider and registered manager were very supportive in a difficult situation and staff said they felt well supported and valued for working additional hours. Their focus was on ensuring the people they cared for were as safe as possible and had their needs met. The registered manager and deputy manager were available in the home to support staff as well as on call. The provider had supported staff by communicating regularly and providing treats and food for staff, including those living in staff quarters on site.

Staff helped people to stay in touch with family and friends through phone and video calls but this was particularly difficult at this time. The registered manager was talking to families as much as possible and working with the local council to ensure supportive communication was maintained whilst focussing on people’s care needs. The home were unable to welcome any visitors at this time but were well prepared for safe visiting as soon as possible.

Further information is in the detailed findings below.

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 delivered care that was kind and compassionate.

There were adequate staffing levels to meet people’s needs. Staff knew people well, understood their needs and cared for them as individuals. People received person centred care and were involved with developing their care plans. Improvements were being put into place so people where possible, and appropriate family members would also be involved reviewing their care plans. People’s care plans and assessments were reviewed each month by the nurses. The operations manager and manger had recognised the need to involve people more if they chose with their reviews.

People’s views and suggestions were taken into account to improve the service. Professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them. Communication with health and social care professionals was being strengthened and improved.

The provider and manager demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. The provider’s operations manager was working with staff to further improve their understanding of the MCA and how to put into practice. 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 eat and drink enough and maintain a balanced diet. People were positive about the food at the service.

The provider had a range of quality monitoring systems in place which were used to continually review and improve the service. There had been two complaints received at the service since our last inspection. These had been dealt with in line with the provider’s policy. The manager was very active around to he and was in discussions with people and relatives to find out their views and if they had any concerns. The home had developed individual personal evacuation plans to support each person in the event of a fire or other emergency. The premises and equipment were managed to keep people safe.

At this inspection the provider was meeting the requirements of the regulations. The provider’s representative and the new manager had identified areas which required further improvement and were taking action to make these improvements.

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 report concerns. Staff training had been reviewed by the new manager and training and updates had been put in place to fill gaps in some staffs’ training. Staff relationships with people were caring and supportive. They delivered care that was kind and compassionate.

People were supported to eat and drink enough and maintain a balanced diet. People and visitors were very positive about the food at the service.

People said staff treated them with dignity and respect at all times in a caring and compassionate way. A designated activity person and staff supported people to take part in social activities.

The provider had a quality monitoring system at the service. The provider actively sought the views of people, staff and health professionals. There was a complaints procedure in place and the manager and operations manager had responded to concerns appropriately.

The premises and equipment were managed to keep people safe.

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.

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'.

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 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.