The Knoll Care Home is registered to provide care and accommodation for up to 34 older people. At this inspection there were 29 people living at the home. The provider offers respite (short stay) care.

The home is a converted Victorian house with purpose built extensions; it has two floors with communal spaces such as lounges and a dining room on the ground floor. There is a garden and courtyard area for people to spend time outside. People were able to freely move between the building and gardens. At this inspection everyone had their own individual bedroom.

At the last inspection, the service was rated Good. At this inspection we found the service remained Good.

Why the service is rated Good

The home continued to ensure people were safe. There were sufficient numbers of suitable staff to meet people’s needs and to spend time socialising with them. Risk assessments were carried out to enable people to retain their independence and receive care with minimum risk to themselves or others. The registered manager and staff continued to encourage people to remain independent. People received their medicines safely and ways were found to reduce the amount of medicines people required. People were protected from abuse because staff understood how to keep them safe and informed us concerns would be followed up if they were raised.

The home continued to ensure people received effective care 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 who required special diets had their wishes respected and meal times were treated as a social opportunity. Staff had creative ways to support people who were struggling to eat or drink. Staff had the skills and knowledge required to effectively support people. People told us and we saw their healthcare needs were met. People were supported to see other health and social care professionals when they required additional support.

The home provided an extremely caring service to people and their relatives. People told us, and we observed that staff were kind and patient and went above and beyond for them. People’s privacy and dignity was respected by staff and their cultural or religious needs were valued. People were involved in decisions about the care and support they received. People’s choices were always respected. People had their end of life preferences recorded and staff ensured these would be carried out.

The service remained responsive to people’s individual needs. Care and support was personalised to each person which ensured they were able to make choices about their day to day lives. Activities provided a range of opportunities both in the home and the community. These considered people’s hobbies and interests and as far as possible reflected people’s preferences. People knew how to complain and the management facilitated a range of opportunities for them to discuss concerns.

The service continued to be well led. People, relatives and staff spoke highly about the registered manager and senior staff. There were times the registered manager would go above and beyond their duties to provide a caring environment for people. The registered manager and provider continually monitored the quality of the service and made improvements in accordance with people’s changing needs. When concerns were raised during the inspection the management were proactive in responding to them.

Further information is in the detailed findings below

This inspection was unannounced and took place on 8 July 2015

The Knoll Care Home is registered to provide accommodation and nursing care to up to 34 people. The home specialises in the care of older people. At the time of this inspection there were 31 people living at the home.

The last inspection of the home was carried out 25 February 2014. No concerns were identified with the care being provided to people at that inspection.

There is a registered manager in post. 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 told us the registered manager was open and approachable and they would be comfortable to make a complaint or raise any worries or concerns. People were also able to share their views at care plan reviews, regular meetings and through annual satisfaction surveys.

Staffing levels were kept under review and people were supported by enough well trained and competent staff to keep them safe. Staff had access to a variety of training to make sure they had the skills required to meet people’s needs.

People were complimentary about the staff who assisted them. One person said “The girls are lovely with you.” Another person told us “The staff are kind and gentle.” Many people commented about the fun they had with the staff who supported them. One person said “We actually have lots of fun.” One person who chose to spend their time in their room said “There’s always someone popping in for a chat and a laugh.” Throughout the day we heard lots of friendly banter and laughter. One person said they liked the home because the staff always seemed happy.

Registered nurses were always available in the home to monitor people’s health needs and ensure they received effective support and treatment. People were referred to other health care professionals according to their individual needs.

People were able to make choices about all aspects of their day to day lives. Everyone we spoke with said they were able to decide when they got up, when they went to bed and how they spent their day. Comments included; “You choose everything,” “They’re pretty good with choices” and “You can please yourself but they’re always around to help.”

People had their nutritional needs assessed and were provided with a diet that meet their needs and preferences. Drinks and snacks were available throughout the day and night. People were able to make choices about the food they ate and where they had their meals.

People were able to take part in a range of activities according to their interests. There was a timetable of organised activities and specialist workers were employed to support people to occupy their time. Some people pursued their own hobbies. There were trips out and events held at the home. There were photos around the house of activities and trips that people had taken part in including a trip to Weymouth the day before the inspection.

We saw that people and their representatives were involved in the planning and delivery of their care. People in the home told us they were treated with dignity and respect by the staff. One person said, “They (the staff) are very respectful and polite here.”

People’s care needs were assessed and care was delivered to meet their needs. People and their relatives spoke highly of the staff at the home and the care they provided. One person said, “They (the staff) are all caring here. They look after me excellently here.” One person’s relative said, “They (the staff) give fantastic care here. I couldn’t wish for more.”

People were protected from harm as there were appropriate safeguarding procedures.

The provider had suitable systems to monitor the quality of service provided.

In this report the name of Alan Icely-Brown appears as the registered manager. They were not in post and not managing the regulatory activities at this location at the time of the inspection. Alan Icely-Brown’s name appears because they were still a registered manager on our register at the time. The home had appointed a new manager in the middle of January 2014, however at the time of the inspection they were still in the process of completing their registration with the commission.

People told us that they were happy at the home and their needs were being met. People told us that they felt that staff were approachable and would sort problems out for them.

People had were not always treated with respect and their dignity was undermined by care staff. People's care was planned but was not always delivered in a way that ensured people’s safety.

The home was clean and processes were in place to ensure that the home was maintained to a good standard.

The staff were supported to meet the needs of the people living at the home.

The provider had some systems in place to monitor the service provided at the Knoll

When we last visited on 1 May 2012 we found that people were able to make decisions about their care and support but care and staff interactions were not always respectful.

We found that people received a good level of personal and social care but were not always protected against the risk of receiving inappropriate health care. Care records contained gaps in information needed to safely plan and deliver people's care. We saw many examples of gaps in recording which may have indicated care had not been provided.

People who used the service were not protected from the risk of abuse, because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff did not have relevant training and records did not demonstrate that decisions were being made in the best interests of people.

People were cared for by staff who were not supported to deliver care safely and to an appropriate standard. This was because of inadequate staff training and supervision.

The provider did not have effective systems to assess and monitor the quality of the service that people received. People were therefore at risk of inappropriate and unsafe care.

At this latest visit we spoke with four people who lived in the home during this latest visit. They told us that staff provided the care and support they needed. People said their privacy and dignity were respected by staff. All the interactions we observed between staff and people who lived in the home were kind and respectful. There was a very relaxed atmosphere. One person we spoke with said “I’m happy living here”.

People who lived in the home told us they felt well cared for and that staff were available when they needed them. People said staff helped them to do the things they needed help with. One person said ”I am happy with my care. I can’t grumble”.

Relatives we spoke with said they though the care in the home had improved. One said “They have new staff who seem better. My husband seems well cared for now”. Another said “Mum is nursed in bed now. The care is better. She used to be so distressed but the staff here helped me change her GP. She is now on much better pain relief. She is much more settled now”.

People told us staff arranged for them to see their GP or other health care staff if they needed to. We saw that the outcomes of these visits were not always recorded. We looked at five people’s care records. They did not accurately describe the care people required.

People we spoke with during this visit said they thought the home was a safe place for them to live. One person said “I feel safe” and another person said “yes I feel safe here”. Visitors we spoke with said the home was now a safer place for their relatives.

Staff were not clear on how to report any concerns they may have. People may not have decisions made in their best interests as staff had not had relevant training.

One relative did say “I think the staff have improved now. I think the nurses and carers are better now”. Some staff training had taken place with additional sessions planned. Formal staff supervisions had not yet resumed.

The manager told us that a full quality assurance process was still not in place. He said he had plans to introduce a thorough system. Safety checks were carried out and some limited auditing had been started.

People were given a choice about their daily lives, including when they got up and went to bed, what they ate at mealtimes and where they spent their day. Some people had chosen to lie in on the morning of our visit and staff respected this choice.

People told us they thought staff treated them with dignity and respect. One person said "They always knock at my door and are very good when I have a bath or shower. They keep the door closed and keep me covered until the last minute."

We saw that the social care needs for people were provided at the home although people were able to choose whether to join in or not. The home had an activity coordinator who planned group activities and one to one sessions for people.

People we spoke with said they felt "well cared for" and "in the right place".

People said staff were "always busy" but answered call bells in a timely way. One person said other staff had often interrupted care staff who were providing care for them. They said this went on for a while but it has stopped recently after their request.

People said they saw their GP when they were unwell and that staff organised this for them.

We saw that not all care was provided in the way it should. Care records and communication of people’s care needs was not always done in a timely or effective way, meaning gaps in care were evident. Some registered nurses had left the home meaning there was an increased use of temporary nurses.

During our visit we spent time observing life in the lounge. We watched interactions between staff and people sitting in the lounge. We saw people were mainly displaying positive signs of well being. We saw that when interaction occurred between staff and people it was good, not rushed and done in a sensitive way. We also saw examples where people were not treated as respectfully. We saw staff use terms of endearment such as sweetheart, love and dear without consent. Two people did not respond to this term of address, but did when staff used their name. We saw three members of staff ignore a person who was calling out. Each member of staff had a task they were performing when they ignored the person.

We also saw an example where the activity coordinator was conducting a quiz which had engaged five people including two with mild dementia. This positive engagement was interrupted by the cleaner coming into the room to vacuum. This caused distress to two of the people.

People told us they felt safe living at the home. We were told that staff were "kind" and "good as gold". People said they would feel comfortable telling any of the staff if they felt unsafe or were unhappy.

We saw good systems for managing peoples finances. A person explained that services such as hairdressing, chiropody and newspapers were paid for by the home and then invoices sent to the family or person.

People liked the staff at the home but commented that there had been a high turnover of staff recently which had been unsettling. People were unaware of what training staff had but we noted that the training programme was inadequate meaning staff had not had essential mandatory training in the past few years.

None of the people we spoke with said they had been formally asked what it was like living at the home. No one was able to recall filling in a questionnaire or survey.

People told us that if they were unhappy about any aspects of life at the home they would speak to any of the staff. People also said they felt confident that any feedback would be listened to and acted upon.

People also told us they did not see the manager much at the home, although staff told us he was present each day. We saw there were no formal methods of monitoring the quality of the service and saw this was done informally as the need arose.

This visit was carried out to follow up outcomes which required improvements following our last inspections in December 2010 and May 2011. We spoke to eight people living in the home and four people visiting relatives.

People spoken with told us that they were generally very happy living in The Knoll Care Home. One person told us that they felt well cared for by staff who understood what they needed. We spoke at length with one visitor who said they were very happy with the level of care their relative received. They said that staff were very caring and understood how to provide care for a person who may have limited understanding.

Two people living in the home and two visitors said that they did not feel the meals were as good as they used to be, one person said they were getting used to the new menus.

We observed staff worked with people in a cheerful, relaxed manner taking the time to talk and discussed day to day events with them.

We spent time talking to people using the service and observing how staff interacted with people.

Each person spoken with commented on the kindness of the staff team and they confirmed that staff were respectful when talking to them or when assisting them with personal care. People told us; “The staff are considerate and kind”, “The staff are amicable and help me with what needs to be done but they don’t have time for a chat”, “I do get the care I need and want”, “It’s caring people doing caring jobs”.

We observed staff interactions with people using the service. These were noted to be kind and respectful. Staff demonstrated a good understanding of people’s needs and how these should be met. We observed staff responding in a very positive way to one individual who became extremely distressed. The individual responded positively to staff interactions.

On the whole, people spoken with were satisfied with the food served in the home however some people did tell us that the quality of the meal was variable. One person said “meals vary depending on who is on duty”.

We spoke to a number of people and nobody knew what was for lunch. One person did say; “well it’s Friday so it will be fish”. Another person told us “the menu used to be displayed in the dining room but this no longer happens”.

People told us they would feel comfortable raising any concerns with the manager or a member of staff and that they felt confident their concerns would be listened to and addressed.

Many people spoken with during our visit commented that the acting manager was not always easily accessible. They said, “You don’t see the manager unless you ask to and I would like the manager to be more visible”, “I asked to see the manager several times as I had a complaint, I did see him eventually and my concerns were dealt with but it was difficult”.

People we spoke to were very complimentary about the staff and the care they received at The Knoll Care Home.

People living in the home told us:

“I am happy living here they are all so nice.”

“It isn’t my home but I know I need to live here now, and it is a good place to live. The staff are always kind.”

“I usually like to sit in this part of the lounge, but if I want to stay in my room they look after me just as well.”

People also commented on the food provided in the home, “the food is always good here; always a choice if there is something I don’t like.”

“I really like the food; the cook is brilliant and comes out to talk to us to find out what we like.”

The people we met said they felt they could talk to all the staff and the manager whenever they wanted to. We saw the manager and staff talking to people in a relaxed and friendly manner.

One relative told us” I am very happy with the way my mother is looked after. I come here quite often and I like the way relatives are welcomed. We have a meeting this afternoon for relatives and they do listen and take on board what you say.”

Another relative said “I am really happy with the food people are offered here, and we can join them at mealtimes if we let them know soon enough. They are always offering people a drink and the cakes are homemade, makes a difference.”