This inspection took place on 26 September 2016 and was unannounced.

Knoll House provides personal care and support for up to 20 people. Care and support is provided to adults, but predominantly to people over 65 years of age. It provides short-term rehabilitation for a period of usually two to three weeks, but can be for up to six weeks. People primarily stay at Knoll House following discharge from hospital, or to prevent an unnecessary admission to hospital. The ethos of Knoll House is to support people to regain their independence and promote independent living skills. Help provided at Knoll House included assistance with personal care, mobility, kitchen assessments, including meal and hot drink preparation, mobility practice, home and/or access visits to assess people’s home environment, stoma education and catheter care.

The short-term rehabilitation is a joint partnership between Brighton and Hove City Council and the Sussex Community NHS Trust who work together to provide co-ordinated care. Consultants for elderly care, GPs and a community mental health nurse visit the service. On the premises people receive support from a social work team, social care staff, medical and nursing staff, physiotherapy and occupational therapy staff. There are a high level of admissions and discharges due to the short-term nature of the service, and there are no long term placements. There were 18 people living in the service on the day of our inspection.

Knoll House is a two story building with a passenger lift for level access throughout the building. All the bedrooms are single occupancy with ensuite facilities. All lounges have kitchen and dining facilities. People are also able to use a conservatory and landscaped garden area. A separate kitchen and gym area is available for people to be supported to work towards their agreed goals for independence.

There was a registered manager for the service. 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 last inspection was carried out on 23 September 2015. We found a number of areas of practice which required improvement. This was in relation to not all the care staff had received training or guidance on Deprivation of Liberty Safeguards( DoLS), and were not aware who had a DoLS agreed. Where people had been assessed at risk of developing pressure sores, the equipment identified to be used had not been regularly checked to ensure it remained at the right setting to meet people’s individual needs. Medicines were kept securely and within their recommended temperature ranges, except for one medicine awaiting disposal that was required by law to be stored in a specific way. Whilst the effectiveness of medicines were appropriately monitored and relevant care plans were available to support the management of most people who lived in the service, the care plan and medicines administration record (MAR) used to record the administration of medicines for one person were not consistent. Some people had food and fluid intake charts being completed. However, records were not all accurately maintained to detail what people ate or drunk, to fully inform the nursing staff. Not all the care staff demonstrated knowledge of people’s individual dietary requirements. The information which had been detailed in individual care plans for staff to follow was variable, had not always been fully completed and did not always give clear guidance for care staff to follow. Where care had changed it was not always possible to identify when this had occurred and the rational for the change. People also told us they would have liked more opportunities to join in social activities. The provider drew up an action plan as to how they w

Our inspection team was made up of two adult social care inspectors. We answered our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we have found. The summary is based on our observations during the inspection. 20 people were resident in the service at the time of our inspection. We observed the care provided, looked at supporting care documentation, staff records and records relating to the management of the service. We spoke individually with the operations manager, the registered manager (who is referred to as manager in the report), the deputy manager, two registered nurses, a physiotherapist assistant, an occupational therapist, a senior social worker, two lead care workers, and three care workers, one of whom was one of the provider’s bank staff. We spoke with eight people who used the service.

Is the service safe?

People were treated with respect and dignity by the care workers. People told us they were safe in the service. Comments received included,” I feel very safe. It’s lovely,” “Feel safe here,” and “Feel very safe here.”

Staff had received training and had an understanding of their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). They knew who to contact should further guidance and support be required to ensure people’s best interests. Where possible, people had been asked for their consent for any care or treatment.

There was a system in place to make sure that the provider, management and care staff learnt from events such as incidents and accidents, complaints, and concerns.

Staff had been provided with training to undertake their roles in the service, systems developed and recording and monitoring systems put in place. This helped to ensure people were not put at any unnecessary risk.

A staff rota was in place, which had taken into account people’s care needs when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people’s needs were met.

Is the service effective?

People’s health and care needs had been reviewed and where possible people and their representatives had been involved in the writing and review of the care documentation. Their specialist care needs such as dietary requirements and support needs had been identified and guidance for staff to follow was in place. People were able to move around the service freely and safely.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and offered encouragement when supporting people. Comments received included,”Like a five star hotel. If you want, you ask, you receive,” “I can’t fault anything,” “Very nice here,” “Very friendly here,” “We have what we want, not what they want,” “Excellent home. I can’t sing their praises high enough,” and “The overall service is very good.”

People had been asked to complete quality assurance satisfaction surveys.

People’s preferences, interests, aspirations and diverse needs had been recorded. People told us care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People had been supported as part of their rehabilitation to meet their agreed goals. People told us they had guidance and regular support from the physiotherapists, and occupational therapists. These specialists had worked with them to improve their mobility prior to returning home. They told us of the exercises they were being supported to undertake. Comments received included, “I saw the physio today,” “I have been for a walk today. I get a walk every day,” and “Exercising every day.“

There was a complaints policy and procedure in place if people or their representatives were unhappy, which was monitored by the provider. Two complaints had been received since the last inspection, which had been responded to appropriately. People told us they had not had to raise any concerns, and they were aware who to speak with if they had any concerns and that they felt they would be listened to. Comments received included, “No complaints here,” and “Not had any worries or concerns.” People could therefore be assured that complaints were investigated and action taken as necessary.

Is the service well lead?

The service had quality assurance systems to develop and improve the service provided, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continually improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the service and quality assurance processes were in place. This helped to ensure that people received a good quality service at all time.

20 people were resident in the home at the time of our visit. There is currently not a registered manager for the service. There is a manager for the service, who has told us that an application for a registered manager is in process, but which has not yet been submitted to the CQC. We spoke individually with the manager, the senior nurse on duty, the nurse lead for medication that day, an agency nurse, two visiting pharmacists, and three care workers on the day shift. We spoke to eight people individually who used the service and three relatives who told us that:

People were able to express their views and were involved in making decisions about their care and treatment.

People told us they felt they were well cared for by staff and that the staff were very caring and responsive to their care needs. Care was provided by care workers who understood their care needs and that their privacy and dignity were respected.

The records for the management of the home were not in all cases accurate and complete or kept securely.

All the care staff we spoke with told us that they had been going through a significant period of change in the home. This was due to the change in regulated activities being undertaken by the service, which had lead to changes in staffing, levels of responsibilities between staff groups and changes in systems within the home.

20 people were resident in the home at the time of our visit. We spoke to 11 people individually who used the service who told us that:

People were able to express their views and were involved in making decisions about their care and treatment.

People's care was provided by care staff who understood their care needs and that their privacy and dignity were respected.

People told us they felt they were well cared for by staff and that the staff were very caring and responsive to their care needs. One person commented, “Its five stars here,” and another commented, “It’s perfect here, I could not wish for anything better.”

People told us that there were always care staff available to assist them with their care needs and that they did not have to wait long when they used the emergency call bells to summon assistance from staff.

People knew who to talk to if they had any concerns and they told us it was an environment where their concerns would be listened to and addressed.

There is currently not a registered manager for the service. There is an appointed manager for the service, who has told us that an application for a registered manager is in process, but which has not yet been submitted to the CQC.

We spoke individually with the manager, representatives from the PCT, a doctor who worked in the intermediate care team, the senior nurse on duty, the nurse lead for medication, an agency nurse, a resource officer, two care workers on the day shift one of whom was a lead care worker and two night care workers.

All the staff we spoke with told us that they had been and were were going through a significant period of change in the home. This was due to the change in regulated activities being undertaken by the service, which had led to changes in designated staff in the home, changes in responsibilities between designated staff and changes in systems and recording formats used within the home.

We obtained information for this Outcome area from surveys, supplied by the provider for people using the service to complete between July and September 2011. The outcome of these surveys recorded that 78% of the respondents stated that their healthcare needs had been met, 63.03% stated that they had been involved in the decision making process, 92.73% stated their privacy and dignity had been respected and 90.30% stated that their privacy had been respected. People we spoke to at the time of our visit and their visiting relatives told us that they were happy with the care provided and had been involved in the drawing up of their care plan.

Staff members we spoke to told us that they were going through a period of change in the home which was unsettling, but that they were receiving the training and supervision they needed to meet individual people’s care needs.

This inspection took place on 23 September and 7 October 2015 and was unannounced.

Knoll House provides personal care and support for up to 20 people. Care and support is provided to adults, but predominantly to people over 65 years of age. It provides short-term rehabilitation for a period of usually two to three weeks, but can be for up to six weeks. People primarily stay at Knoll House following discharge from hospital, or to prevent an unnecessary admission to hospital. The ethos of Knoll House is to support people to regain their independence and promote independent living skills. Help provided at Knoll House included assistance with personal care, mobility, kitchen assessments, including meal and hot drink preparation, mobility practice, home and/or access visits to assess people’s home environment, stoma education and catheter care.

The short-term rehabilitation is a joint partnership between Brighton and Hove City Council and the Sussex Community NHS Trust who work together to provide co-ordinated care. Consultants for elderly care, GPs and a community mental health nurse visit the service. On the premises people receive support from a social work team, social care staff, medical and nursing staff, physiotherapy and occupational therapy staff. There are a high level of admissions and discharges due to the short-term nature of the service, and there are no long term placements. There were 18 people living in the service on the days of our inspection.

Knoll House is a two story building with a passenger lift for level access throughout the building. All the bedrooms are single occupancy with ensuite facilities. All lounges have kitchen and dining facilities. People are also able to use a conservatory and landscaped garden area. A separate kitchen and gym area is available for people to be supported to work towards their agreed goals for independence.

There was a registered manager for the service. 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 going through a significant period of review, where the provider and local stakeholders were looking at the service provision and what was needed and how the service would best be provided in the future.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards. Senior staff had policies and procedures to follow and demonstrated an awareness of where to get support and guidance when making a DoLS application. Not all the care staff had received training or guidance on DoLS, and were not aware who had a DoLS agreed. This meant there was the possibility of a lack of consistency of the care provided and agreements as part of the DoLS application not being followed. We have identified this as an area of practice that needs improvement

Where people had been assessed at risk of developing pressure sores, the equipment identified to be used had not been regularly checked to ensure it remained at the right setting to meet people’s individual needs. We have identified this as an area of practice that needs improvement.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place for the proper and safe management of medicines. However, one medicine awaiting disposal was not being stored in a specific way as was required by law. Guidance on the care plan and medicines administration record (MAR) used to record the administration of medicines for one person were not consistent to ensure a consistent approach when administered. We have identified this as an area of practice that needs improvement.

People's individual care and support needs were assessed before they moved into the service. Care and support provided was personalised and based on the identified needs of each individual. People had a care and support plan and risk assessments in place, which had been reviewed. The detail for staff to follow was variable and did not always give clear guidance for care staff to follow. Charts in place to monitor people’s food and fluid intake and to ensure that pressure relieving equipment was set to meet people’s individual requirements had not been consistently recorded. This meant there was a risk that care would not be provided consistently. However, staff told us that communication throughout the service was usually good and included comprehensive handovers at the beginning of each shift and regular staff meetings. They felt they knew people’s care and support needs and were kept informed of any changes. Senior staff used handover notes between shifts which gave them up-to-date information on people’s care needs. We judged this had not impacted on the care that people had received, but is an area which needs to be improved upon.

People told us they felt safe. They knew who they could talk with if they had any concerns. They felt it was somewhere where they could raise concerns and they would be listened to. One person told us, “It’s a lovely place to be.” The service was clean was a maintenance programme in place which ensured repairs were carried out in a timely way. Regular checks had been completed to ensure equipment and services were in good working order.

Senior staff monitored peoples dependency in relation to the level of staffing needed to ensure people’s care and support needs were met. Staff told us they were supported to develop their skills and knowledge by receiving training which helped them to carry out their roles and responsibilities effectively. Training records were kept up-to-date, plans were in place to promote good practice and develop the knowledge and skills of staff.

People told us they had felt involved in making decisions about their care and treatment and felt listened to. They were treated with respect and dignity by the staff, and were spoken with and supported in a sensitive, respectful and professional manner. One person told us, “They respect my dignity and encourage my independence.” Peoples healthcare needs were monitored and they had access to health care professionals when they needed to. People spoke about the support they had received as part of their rehabilitation. One person told us, “With the help of people here I can get back to what I was.” Another person told us,“I am aiming to go home and working with the physiotherapists”. One member of staff told us, “The service works well for people who are able to be rehabilitated.”

People’s nutritional needs had been assessed and had a selection of choices of dishes to select from at each meal. People said the food was good and plentiful. One person told us, “It’s very nice food, homely cooking. If I didn’t like what I had chosen I could ask for something else.” Staff told us that an individual’s dietary requirements formed part of their pre-admission assessment and people were regularly consulted about their food preferences.

People and their representatives were asked to complete a satisfaction questionnaire at the end of their stay. We could see people were able to comment on and be involved with the service provided to influence service delivery. The registered manager told us that senior staff carried out a range of internal audits, and records confirmed this. The registered manager also told us that they operated an 'open door policy' so people living in the service, staff and visitors could discuss any issues they may have.