We inspected The Knoll on 4 December 2018. The inspection was unannounced.

The Knoll is a ‘care home’ and provides accommodation and personal care for up to 34 older people living with dementia. 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. At the time of our visit 21 people were using the service.

The Knoll is situated on the side of Robinswood Hill and is situated in large grounds with views overlooking Gloucester. This was an unannounced inspection.

We last inspected the home on 20 and 21 September 2017 and found one breach of the legal requirements. We asked the provider to take action to make improvements so people would receive their medicines as prescribed. During this inspection we found that improvements had been made to ensure peoples medicines were administered as prescribed and the provider was meeting the requirements of the regulations.

The service did not 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. There have been two previous registered managers since our last inspection in September 2017. The present manager took up post in September 2018. They had submitted their application to become registered manager and was being processed by CQC.

The manager had been proactive in identifying shortfalls in the service which had developed as a result of several management changes. They were taking action to address staff refresher training and supervisions as well as record keeping across the service. We found improvements were starting to take place, however these needed to be embedded across the service and sustained. More time was needed to evaluate the effectiveness of the newly implemented auditing processes and improvement plans.

There was a clear vision for the delivery of good quality care to people and a positive culture within the staff team.

People told us they felt safe living at the home and we saw there were effective safeguarding processes in place to protect people from the risk of harm. Staff were knowledgeable about the procedures relating to safeguarding and whistleblowing.

Safe recruitment checks were carried out and there were adequate numbers of staff to meet people's needs safely.

Risks to people had been assessed and managed appropriately. There were also systems in place to check and maintain the safety and suitability of the premises.

People's health care needs were assessed, reviewed and delivered in a way that promoted their wellbeing. People were encouraged to eat and drink well, and they were referred to healthcare professionals when required.

People who lived at the home were positive about the care provided. They were treated with kindness and compassion and they had been involved in the decisions about their care where possible. People were given respect and, their privacy and dignity was maintained and their independence promoted.

People knew how to make a complaint and these were responded to within the timescales in the provider's policy. Staff felt able to raise concerns or issues with the registered manager.

Staff induction training and mandatory training had been completed as required by the provider's policy. Plans were underway to ensure staff one on one supervision and refresher training were provided in line with the provider's policy.

We inspected The Knoll on the 20 and 21 September 2017. The Knoll provides accommodation and personal care to 34 older people and people living with dementia. At the time of our visit 24 people were using the service. The Knoll is situated on the side of Robinswood Hill and is situated in large grounds with views overlooking Gloucester. This was an unannounced inspection.

We last inspected the home on 28 and 29 June 2016 and found one breach of the legal requirements. We asked the provider to take action to make improvements in relation to protecting people from the risks of infection. During this inspection we found that improvements had been made to ensure people were protected from the risk of infection.

There was a registered manager in post. The registered manager was also the provider of 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.

People did not always receive their medicines as prescribed. Effective systems to manage and monitor people’s medicines were not continually in place.

People enjoyed living at The Knoll. People told us they were safe at the service and enjoyed active and social lives. People had access to activities and discussions from staff which were tailored to their individual needs and preferences. People felt cared for and happy.

People were supported with their on-going healthcare needs. Care staff supported people to access the healthcare support they required. People told us they enjoyed the food they received within the home, and had access to all the food and fluids they needed. Where people needed support to meet their nutritional needs, these needs were met.

People were supported by staff who were supported and trained to meet people’s individual needs. Staff were supported to develop and access additional training to further improve their skills. The registered manager had implemented a number of changes to the environment which had made the service more dementia friendly. People and staff positively discussed these changes.

People and their relatives spoke positively about the management of the service. The registered manager ensured people, their relatives and external healthcare professionals’ views were listened to and acted upon. The registered manager had systems to assess, monitor and improve the quality of service people received at The Knoll.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

This unannounced inspection took place on 28 and 29 June 2016.

The Knoll provides residential and respite care for up to 34 people. At the time of our inspection 23 people were living there. There was no 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. A new manager has recently been employed and the intention was for them to become the registered manager for the service. There were no breaches of legal requirements at the last inspection in September 2014.

All areas in the home were not clean and infection control procedures were not always followed. This required improvement. Quality assurance procedures identified when action was necessary but action was not taken to improve the service with regard to cleanliness. People had commented they may have to wait longer for assistance at the weekend when there was no manager available.

Peoples lived in an environment which could be more ‘dementia friendly’. We made a recommendation to improve this. People were provided with personalised care and were supported to make their own choices and decisions where possible. Relatives had signed consent when they were not legally able to. This in not in line with the Mental Capacity Act 2005 (MCA). People’s care was not always regularly reviewed to record progress and make changes.

People were usually treated with kindness and they told us staff were good when they supported them with their care. Staff knew how people liked to be supported. People told us they felt safe in the home. Staff knew how to keep people safe and were trained to report any concerns. People were supported by staff that were well trained and had access to training to develop their knowledge. End of life care was planned and people and their relatives were supported by the staff and healthcare professionals.

People told us the food was good and there was a choice of meals. They had home cooked cakes and pastries to choose from. People nutritionally at risk were monitored and appropriate meals and drinks were provided.

People had activities to choose from which included quiz games, exercise classes, pet therapy, arts and crafts and music therapy. Care staff had helped to provide activities for people when there was no activity coordinator but there had been less individual engagement with people. An activity co-ordinator had recently been employed and improvements to activities had begun.

The new manager and the area operations manager, representing the provider, monitored the quality of the service with regular checks. People and their relative’s views and concerns were taken seriously. They contributed in meetings and were provided with a record of the meetings. Staff felt well supported by the manager and the area operations manager who were available to speak to people, their relatives and staff. Staff meetings were held and they were able to contribute to the running of the home.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

An adult social care inspector carried out this inspection. The focus of the inspection was to answer three key questions; is the service safe, effective and well-led?

As part of this inspection we spoke with three people who use the service, five care staff and two representatives of the provider. We observed staff interactions with people who use the service and observed the support being given to some people. We reviewed records relating to people's care as well as records relating to the management of the service. For example, staff duty rosters, staff training and developmental records. We also reviewed records pertaining to how services were monitored and improved.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

The service was safe because staff understood the needs of the people who use it and what support they required.

Staff had a good understanding of what their individual responsibilities were in relation to safeguarding people from abuse. Staff were better equipped to challenge poor care and report their concerns. Senior staff had the right skills and were also better equipped to manage concerns or allegations of abuse that were reported to them.

The service had been staffed according to people's needs and the level of support they required. There were arrangements in place that ensured there were enough staff on duty in situations for example, where staff went off sick.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications needed to be submitted proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

The service was effective because staff had been trained in subjects relevant to their role and in legislation that helped to protect people. The provider's policies and procedures were being adhered to, for example, staff were receiving the correct induction training.

Care records were effective because they had been maintained and gave staff up to date information on people's needs and health risks.

Is the service well led?

The service was well led despite the service not having a home manager in place. Arrangements had been made for a previously known manager to return to the service soon and on a permanent basis. People who used the service and who had known the previous manager were happy about this. One person said, "Oh we are so pleased, he's lovely." Until this point arrangements had been made to ensure the service was managed on a daily basis by a competent person. Representatives of the provider had provided management support and had monitored the service's performance.

Improvements had been made to how staff were trained and supported.

We spoke to five people who used the service. One person said "I cannot fault them (the staff), they are all lovely and helpful". When talking about the new registered manager (in post for five months) one person said "That young man has made such a difference". We spoke to one relative who said "Things are much improved. Things get followed up now and I can discuss any concerns I may have and they are dealt with". We inspected people's care records, which had improved greatly since our last inspection in August 2012. People's care plans were personalised, regularly reviewed and updated as their needs altered. People had access to external health professionals' support as needed. People's health risks were being assessed and monitored. Staff were being supported and receiving training to provide people's care safely and staff communication had improved. The home looked clean and was free of odours. Although systems were in place to reduce the risk of infection spreading, these needed to be reviewed to ensure current best practice was in place.

This was a follow up inspection of the service following our previous inspection on 3 January 2012 when the service was found to be non compliant in seven outcomes. During this visit the service was found to be compliant in all of these outcomes.

People who use the service told us they felt well cared for and their needs were being met.

One person said "the staff are very good" and another said "my carer always gives me a bath, which I enjoy. I like her to do it and we decide which day is best for both of us".

The care records told us that people were having their care tailored to their needs and that any potential health risks were being monitored. People had access to external health care specialists as required. People who had additional or specific needs were having these met. It was evident that people's choices and preferences, if known, were being considered and met where possible.

Several care staff had left since our last visit but some new staff had already been recruited and the recruitment of more staff was ongoing. The service was using agency staff to fill gaps but the same agency staff were being used so continuity of care could be maintained. Existing staff and new staff had received training since our last visit to help them acquire the correct level of skill and confidence required to meet people's needs.

The service had a new manager who was receiving support from the provider to improve standards of care and service provision.

We received very few comments back from people when we asked whether they felt cared for and their needs met.

One person did tell us that she felt that her needs were being met and that the staff were helpful and kind. She said that the staff gave her help where she needed it.

Most people we asked about the food told us they enjoy it.

Three people expressed irritation at the noise Children's TV was making whilst being shown on the television.

On asking people what they did with their time, one person said "not a lot, we sit here" and another said "there's not a lot going on".

This inspection was completed by one inspector who visited the service on three separate days.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five 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 after speaking with people who use the service, staff who worked in the service and representatives of the provider. We observed care and support being delivered and inspected relevant records.

Is the service safe?

Arrangements were in place to identify, assess and monitor specific risks to people. Measures had been put in place to reduce the risks associated with activities that some people wished to continue, such as smoking.

We observed staff responding to people’s basic needs when required.

Staff had been trained in how to respond to an allegation of abuse. Information had been made readily available to help staff report abuse appropriately but procedures were not followed in the case of one reported allegation. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Senior staff had been trained to understand when an application should be made.

Is the service effective?

People told us they were happy with the care and support they received. Care plans gave specific guidance for staff to follow in relation to people's individual needs. People were receiving the care that was stated in their care plans. These plans were kept up to date and relevant and care staff had access to them. One person said, "they (the staff) look after me".

We observed limited but good communication with people who had dementia and this usually led to people's well-being.

Is the service caring?

One person who uses the service said, "people (the staff) are very kind". We observed a fondness between people who use the service and the staff that cared for them. People were relaxed in staff members' company. Staff were aware of people's diverse needs and were kind towards people who required additional support. People were respected and where they were able to be independent staff supported this.

Is the service responsive?

When needed staff worked with visiting health care professionals to ensure people's health care needs were met.

Some comments from people who use the service and the staff showed that it was not always possible for staff to meet people’s specific preferences. People's basic needs were being met but for example, one person's wish to have a shower more frequently than once a week could not be accommodated because they told us staff did not have enough time. People without family members to take them out had limited opportunities to go out and be part of the wider community because staffs' priority was to deliver people's basic care. People who required additional time to communicate with and support, such as people with dementia, could not always be afforded this. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

People were supported to make choices about the activities held inside the home and they had a choice of food.

Is the service well led?

Staff had not always been provided with adequate support to professionally develop. Some staff required training in subject’s key to their roles and responsibilities to enable them to carry these out safely and correctly. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

There was a system in place to assess and monitor the services being provided to people but evidence showed that important shortfalls, that potentially had an impact on people who use the service, had not been identified. Staff told us they were "undervalued" and "unappreciated" by the provider. The provider's engagement with their staff had clearly been poor. This meant that the provider's system was not giving them sufficient information about how the service was running. We were told that a new system had been devised which would improve the monitoring and support given to the service, but this had not yet started. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Evidence also shows that the service runs smoothly and levels of compliance improve when it is managed in an effective and consistent manner. However, since the service registered under the Health and Social Care Act 2008 in January 2011 there has only been one period, of approximately a year, when the service has had consistent and effective management by a registered manager. People who use the service and the staff confirmed that the new manager, who started managing the service in January 2014, was approachable and supportive. This manager has not yet applied to us to be the registered manager of the service.

In this report the name of two registered managers appear who were not managing the regulated activity at this location. Their names appear because they were still on our register at the time as managing the activity at this service. We had advised the provider of what they needed to do to remove one individual's name from our register and this process has been completed. The second name will be removed from the register by us as the person has not responded to our request to remove themselves.