Knowsley Manor Nursing Home is a ‘care home’ that provides nursing care for a maximum of 50 people. At the time of the inspection there were 36 people living at the service. 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.

There is no registered manager working at the service. There was however a manager in post who was responsible for the day-to-day running of the service. The manager had applied to CQC to become the 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.

We carried out this inspection on 10, 15 and 18 May 2018. The first day of the inspection was unannounced and the other two days were announced.

At the last inspection, in June 2016, the service was rated Good. At this inspection we found improvements were required in relation to safe and effective care for people.

Medication was managed safely overall. However, on the first day of inspection thickening powder prescribed to people to modify their fluids was left unattended in a dining room which was occupied by people. If ingested thickening powder can cause a person to choke. The powder was stored away safely on the other two days of inspection. All other medication was safely stored and administered to people and there were safe systems in place for the receipt, disposal and returning of medication to the supplying pharmacist. People were administered their medication on time by suitably trained staff.

Call alarm bells were in place around most part of the service, however there were two toilets and two bathrooms without one. This meant that there was no means for people to alert staff should they need to when using those rooms independently. The manager immediately contacted the relevant department within the organisation to arrange for call alarm bells to be fitted and this done by the end of our inspection. Cleaning schedules were in place and being followed. The environment was clean and hygienic and smelt pleasant throughout. Staff followed good infection prevention and control practices to minimise the risk of the spread of infection.

Care plans were in place for people’s assessed needs and they included directions for staff on how to meet them. This included the completion of charts to record the care given. Some people’s charts did not include information about their care needs and others did not reflect the care given. Staff assured us that people had received the right care and we did not evidence any impact on people. However, there was no guarantee that people had received the right care and support in line with their care plan.

People were offered a choice of food and drink which was prepared in line with their dietary needs which were well documented. However, meals were not always well presented. Each element of a pureed meal for one person was mixed together in a bowl making the meal look bland and unappetising. Bread was placed on the edge of soup bowls rather than people being provided with a side plate. In one instance the bread fell into a person's soup and they struggled to eat it.

The quality and safety of the service was assessed and monitored. The required checks had been carried out and improvements made in line with the registered providers quality assurance framework. However more regular checks were required to ensure records about people’s needs and the care given were accurately completed and maintained. More robust checks to ensure people’s safety were also required in relation to the storage of thickener, presentation of meals and accessibi

This inspection was carried out over two days on 10 and 14 June 2016. The first day of the inspection was unannounced.

Knowsley Manor Nursing Home accommodates up to 48 people who require personal and nursing care. The service is situated close to Knowsley village. There were 47 people living at the service at the time of this inspection.

The service has a registered manager who was registered with the Care Quality Commission in December 2014. 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 of the service was carried out in July 2014 and we found that the service was meeting all the regulations that were assessed.

We have made a recommendation about monitoring the quality of the service. Checks were carried out at various intervals on things such as people’s care records, medication, the environment and infection control practices. However some checks on the cleanliness of the environment were not always effective. Some parts of the service people occupied and equipment used to help people with their mobility was unclean which increased the risk of the spread of infection.

The registered provider had a recruitment and selection policy which described a safe and fair procedure for employing new staff. Applicant’s suitability to work at the service was assessed based on information which they were required to provide. This included details about their previous employment history, skills and experience. In addition they underwent a series of pre-employment checks on their character before they started work at the service.

People were protected from avoidable harm and potential abuse because the registered provider had taken steps to minimise the risk of abuse. Clear procedures for preventing abuse and for responding to an allegation of abuse were in place. Staff were confident about recognising and reporting actual or suspected abuse and relevant staff were aware of their responsibilities to report abuse to relevant agencies.

There were safe systems in place for managing people's medicines. Medication was stored safety in dedicated rooms which were clean and tidy. Each person had a medication administration record (MAR) and a medication information sheet detailing their prescribed medication and any instructions for use. People received their medication on time by staff who had received the appropriate training and were deemed competent to carry out this role. When required people had accessed healthcare professionals such as GPs and specialist nurses.

People told us they had plenty to eat and drink. People’s nutritional and hydration needs were appropriately assessed and planned for. People received the support they needed to eat and drink and those who required it, had their weight, food and fluid intake monitored. Appropriate referrals were made on behalf of people to dieticians and speech and language therapists when there were changes in people’s needs.

People’s needs were understood and met by the right amount of suitably skilled and qualified staff. We received no concerns about the staffing levels. Family members told us there were enough of the right staff on duty to meet their relative’s needs.

People’s care plans contained good information about how people’s needs were to be met. Care plans were reviewed regularly and they reflected people’s current and changing needs. Daily records showed that people’s needs were met in accordance to their wishes and preferences which were set out in their care plans.

The registered manager and staff had a good knowledge and understanding of the Mental Capacity Act (2005) and their roles and responsibilities linked to this. They worked relevant others to ensure d

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?

People said they felt safe living at the home and relatives of people who used the service told us they had no concerns about people's safety. Comments included, "Yes, very safe." “Yes I can leave here knowing my mum is safe and in good hands.” And “Definitely safe, I trust them.”

Staff had received the right training to safely meet people’s needs.

Appropriate plans were in place to manage any risks to people’s health, welfare and safety.

Policies and procedures were in place relating to the Mental Capacity Act and Deprivation of Liberty Safeguards and relevant staff understood when an application should be made, and how to submit one. This meant that people's rights would be safeguarded as required.

Is the service effective?

People’s needs were assessed and planned for with their involvement or the involvement of their relatives.

Staff communicated effectively with people who used the service and people responded positively to staff.

Staff had been trained to an appropriate standard to enable them to meet the needs of the people who used the service.

Is the service caring?

Staff were polite, respectful and patient towards people who used the service and their relatives.

Staff spent time reassuring people who were anxious and people benefited from the support staff gave them.

Staff encouraged people’s independence and as a result people who used the service regained daily living skills.

Is the service responsive?

Staff responded to any concerns they had about a person's health or wellbeing which resulted in people receiving appropriate care and support when they needed it.

People who used the service felt confident about sharing their views and opinions about the service and they said they were listened to.

Systems which were in place at the home ensured any improvements were identified and responded to quickly.

Is the service well-led?

The service worked well with other agencies and services to make sure people received the right care and support.

The service had quality assurance systems which help make sure the service made continuous improvements.

Staff told us they were clear about their roles and responsibilities and that they could approach the manager if they needed any support or advice regarding their work.

People who used the service and their relatives told us that they thought the home was well managed and that they felt able to express their views and opinions about the service.

The provider informed us that the care plans that were under review included a dedicated consent form that would be signed by the person using services and/or a family member. During our visit, we continually observed people being given choices related to food, where and what they wanted to eat and any planned activities. We noted that all people had comprehensive assessments with detailed risk assessments which highlighted their individual needs, preferences and diversity while detailing how these would be managed and reviewed in the future. We observed medication was handled and disposed of appropriately and all senior staff who were responsible for administration were all fully trained. People told us`we have our medicines around the same time every day` which protected their welfare.

An effective recruitment process was in place at Knowsley Manor which ensured all required safety checks were completed before new staff started work. Available staff training files were inspected and found to be up to date. Staff supervisions were held every other month and full appraisals were conducted on an annual basis. People we spoke with were happy their `comments and complaints would be listened to and acted on`. People using services were aware of the complaints procedure and the provider informed us that all `comments would be considered fully and responded to appropriately and resolved within an acceptable time-frame`.

We spoke with people who used the service, relatives and carers, staff and visiting healthcare professionals. We used a number of different methods to help us understand the experiences of people living at Knowsley Manor Nursing Home. This was because some of the people who used the service had complex needs which meant they were not able to tell us their experiences.

We observed during our inspection that the people who used the service appeared happy and content living there. We found people were treated respectfully and given support to have their say in how they wanted to be helped and were supported to do the things they wanted to do.

The people who lived at Knowsley Manor Nursing Home were cared for by staff who were appropriately recruited, well trained and experienced at supporting them.

People told us and our observations found that people’s immediate needs were well attended to. People were treated with care and consideration. However we observed that some staff were more focussed on completing tasks for people, rather than acknowledging and engaging with them.

We saw evidence of robust care planning that had been personalised and addressed specific individual needs.

We saw a complaints policy and information about how to make a complaint was available in communal areas.

We saw that there were appropriate systems in place to monitor the quality of care that people received at the home.