Hollin Knowle 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. Personal care is provided in one adapted building for up to 19 older people.

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. S

This inspection was unannounced and took place on 6 and 14 February 2017. It was carried out by one inspector and specialist advisor in nutrition.

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.

The inspection was carried out by a CQC inspector. We spoke to four people using the service, two family members, a visiting health and safety inspector, the service manager and three members of staff. Below is a summary of what we found.

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.

There were 17 people using the service at the time of this inspection. We spoke with four people, two visiting relatives, and three staff.

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.

There were 17 people using the service at the time of this inspection visit. We spoke with three people, a visitor, and three staff.

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.

There were 19 people in the home at the time of this inspection. We spoke with five people using the service and with three visitors. The people and visitors we spoke with were mostly positive about the service provided. One person told us, “I like it here, it’s like home”. We received comments prior to our visit that moving and handling at the home was not in line with current good practice guidance. Also, comments that people were not always given choices of food and drink.

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.

There were 18 people using the service at the time of our visit. We spoke with six people to gain their views of the service. Some people in the home had limited communication abilities and so we could not interview them to find out their views. However, we were able to observe their mood and behaviour and how they interacted with staff. We also spoke with four relatives of people in the home.

One person told us "They look after me very well" and another person said "I’m very comfortable here". One relative told us they were pleased the person "has settled so well here" and said the person's health had improved since moving into the home.

We observed positive interactions between people in the home and staff. We found there was a relaxed atmosphere in the home. One person told us that staff were "friendly - we always have a laugh".

This unannounced inspection was carried out on the 23 and 30 September 2015. Hollin Knowle

provides accommodation and personal care for up to 19 older people. At the time of the inspection there were 17 people living in the home. Most of the people had physical difficulties and memory loss.

The service has 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.

During the last inspection carried out in June 2014 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 These were in relation to ensuring people gave consent to their care and ensuring the safety of people in relation to recording incidents. At this inspection we found action had been taken and these issues had been addressed.

Some people’s health was not always promoted because medication was not administered, recorded, and managed appropriately. This was a breach of the Health and Social Care Act and you can see what actions we told the provider to take at the back of the full version of this report.

People were protected from avoidable risks and staff were aware of their duty of care to protect people. Staff were trained to recognise and respond to signs of abuse. Risk assessments of people’s health and welfare and the safety of the environment were carried out and reviewed regularly.

The staff had appropriate training, supervision and support, and they had some understanding of their roles and responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People’s nutritional and dietary requirements were met and a nutritionally balanced diet was provided. However there were no meal choices available. We noted that people appeared to enjoy their food.

People were not supported to pursue their hobbies or interests and they were not stimulated. People we spoke with said they were bored.

People were supported to access other health and social care professionals when required, and encouraged to continue their relationships with their family members and friends.

Staff were caring, kind and compassionate and cared for people in a manner that promoted their privacy and dignity. People felt listened to and had their views and choices respected. However people who needed assistance with eating were not always assisted in a manner that promoted their dignity.

People were involved in making decisions about their care and support. Individual care plans provided information for staff on how to assist and support people in meeting their needs. The care plans were reviewed and updated regularly.

The home was managed in an inclusive manner that invited people, their relatives and staff.to have an input into to how the home was run and managed. There were systems in place to assess, review and evaluate the quality of service provision. However these were not always effective.