This inspection took place on 21 and 23 August 2018. The visit on 21 August 2018 was unannounced. The visit on 23 August 2018 was announced.

The Knowles is a residential care home which provides accommodation and personal care to older people including those living with dementia. It is registered to accommodate a maximum of 38 people. On the days of our inspection visits there were 33 people living in the home.

People in care homes receive accommodation and 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.

The accommodation is set out over two floors, the first floor being reached by a lift. There are three separate lounge/dining areas and an accessible garden.

There was a new manager in post but they were not registered with us. 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 new manager took up their post on 22 August 2018, in between our two inspection visits. The deputy manager had been ‘acting manager’ and had returned to their original role.

At our previous inspection in April 2017, we rated the service as Requires Improvement. This was because the service was not as consistently safe, effective or as responsive to people’s needs as it should have been, and the service was not consistently well led. For example, risks to people’s care were not always managed safely. People did not always receive personalised care and at times staff did not respond to people’s needs in a timely way. How quality monitoring systems were implemented did not ensure the home was consistently well led.

At this inspection we found some areas of improvement. However, we also identified some issues that meant the service remains rated ‘Requires Improvement’ overall.

Incidents had not always been appropriately recorded or investigated to identify how safety issues could be resolved. The lack of completed incident reports, meant the manager had not been able to investigate and categorise the incidents to see if a referral to the local safeguarding authority was appropriate. The provider had not notified us of all the safeguarding referrals that had been made to the local authority in accordance with their legislative responsibilities. The provider’s quality assurance systems had not identified these issues.

There were enough staff to provide safe care, but staff were very busy and sometimes did not have time to engage with people as they wished to. The suitability of staff was checked during recruitment procedures to make sure they were safe to work at the home. Staff received an induction and training to ensure they had the knowledge and skills to meet people’s needs effectively.

The provider used a range of recognised risk assessment tools to identify people’s individual risks, but there was inconsistency in the level of information staff had to manage risks. Records to evidence risk management needed to be improved.

People had an assessment completed before moving to the home to make sure staff could meet their care and support needs. People’s healthcare needs were monitored by staff and any concerns were referred to other healthcare professionals. People’s medicines were managed, stored and administered safely.

Since our last inspection the provider had reviewed the nutritional support people received and introduced some initiatives to ensure people had enough to eat and drink and had a more enjoyable lunchtime experience.

People appeared to be happy living at the home and during our visit we saw some genuine, empathetic and kindly interactions between staff, people and relatives. Staff treated people with dignity and res

This inspection took place on 10, 12 and 13 April 2017. The visits on 10 and 12 April were unannounced. The visit on 13 April was announced. At our last inspection in January 2015, this service was rated as ‘good’

The Knowles is a residential care home which provides accommodation and personal care to older people including those living with dementia. It is registered to accommodate a maximum of 38 people.

On the days of our inspection visits there were 32 people living in the home. There was one person who was in hospital.

There was a new manager in post but they were not registered with us. 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 provider had ensured the home was supported by a ‘compliance’ manager from within the organisation in the absence of a registered manager. The new manager who is referred to throughout this report as the “care manager” had been in post for one week at the time we carried out our inspection.

People living at The Knowles told us they felt safe. Care staff understood their responsibilities in being observant at all times to keep people safe. However, there were periods of time when communal lounges were not occupied because staff were needed to support people elsewhere in the home. This placed some people at increased risk of falling due to them not waiting for staff assistance to walk. There had been a high number of falls in the home and it was not evident these were always effectively managed.

Staff knew how to recognise abuse or poor practice and told us they would report abuse if they observed this happening. We found that not all reportable incidents related to people’s health and safety had been reported to us. We found that information related to risks associated with people’s care was not always clearly recorded and risks were not consistently managed.

There was a computerised medicine administration system in place. Records related to creams and lotions did not reflect these had always been applied as prescribed.

There were recruitment checks and systems in place to ensure staff were safe to work with people at the home. Staff received an induction to the service when they started work. They also had access to a range of training to maintain and update their skills and knowledge so they could meet people’s needs safely and effectively. Staff practice was observed and they had supervision meetings so their competence could be assessed to ensure they worked to the provider’s policies and procedures.

Staff had been supported with training to help ensure they understood how people who lacked capacity could be supported to make decisions. Staff knew they could not undertake care practices against the wishes of people in the home. The management team had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People had been assessed to determine how decisions could be made in their best interests and applications for DoLS had been completed. Authorisations that had expired had been reapplied for.

We observed staff were caring in their approach and people considered staff to be kind and caring. Most of the time, when staff were available in the communal areas, they were responsive to people’s needs.

Social activities were provided for people and work was ongoing to ensure these were meaningful activities for the varying needs and dependencies of people at the home. Staff knew about people’s wishes and preferences in relation to their care and aimed to support people in accordance with these.

People were provided with a choice of food and drinks. Drinks were regularly provided throughout the day and

The inspection took place on 26 January 2015 and it was an unannounced inspection.

The Knowles is a care home that provides personal care and support to older people with dementia. It is registered to accommodate a maximum of 38 people. On the day of our inspection there were 35 people living in the home.

The home 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.

The registered manager had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Staff had been given training to help ensure they understood how people who lacked capacity could be supported to make decisions. Some staff remained unclear on their responsibilities under this legislation although they knew not to undertake care practices against the wishes of people who lived in the home. We saw people had been assessed to determine how decisions could be made in their best interests and applications for DoLS had been completed and were in the process of being submitted for approval to the Local Authority.

People living at The Knowles told us they felt safe. Staff knew how to recognise abuse or poor practice and told us they would report abuse if they observed this happening. Care staff understood their responsibilities in being observant at all times to keep people safe. Staff communicated any concerns at the handover between shifts so any risks to people’s health and welfare could be managed. There were plans in place for staff to follow in the event of an emergency, such as a fire, to make sure people were kept safe.

People were provided with food that met their identified health needs. Choices of drinks were available during the day but we noted there was a delay in some people receiving a drink when they got up in the morning. Where people had lost weight, or there were concerns regarding their health, their food and fluid intake was monitored to make sure they were having enough to eat and drink.

People received their medicines as prescribed. Staff told us appointments with health professionals such as the GP and district nurses were arranged to support people’s health needs when required.

Social activities were not necessarily focussed on people with dementia and were not always person centred in accordance with people’s interests and wishes. We observed there were suitable numbers of trained staff on duty to meet people’s care needs but occasionally some people received delayed support. Everyone spoken with considered staff to be kind and caring and told us they were available when they needed them. People and visitors were positive in their views of staff and stated they would feel comfortable raising any concerns if they needed to.

People and their relatives were encouraged to provide feedback about the quality of care and services in the home. Quality satisfaction questionnaires seen showed positive responses. Areas needing improvement were discussed during staff meetings so they could be actioned.

During our visit we spoke with six people and one visitor. Many of the people who lived at The Knowles had dementia so we also observed what their experiences were like across the three lounge/dining areas in the home. People we spoke with told us they were satisfied with the care they were receiving. Comments included: “They look after me ok here”. “It’s alright, I like it here”.

People told us they liked the meals and enjoyed the entertainment provided. Social events planned were displayed on the notice board in the home.

During our last inspection we found improvements were needed to ensure compliance with the standard relating to records. During this inspection we found sufficient improvements had been made. Care plans for people provided staff with sufficient information to deliver care safely. Where there were risks associated with peoples care such as falls, risk assessments had been completed to assess and manage these risks.

The service had systems in place to ensure medication was administered safely.

We saw that staff had access to regular training to ensure they had the skills to deliver care safely and appropriately to people. Newly recruited staff had completed full induction training.

The service had processes in place to gather the views of the people and visitors to make sure the quality of service provided was in accordance with their expectations.

We made an unannounced visit to this care home on Friday 8 June 2012.

We spoke with ten of the 34 people using the service at the time of our inspection. Some people using the service at The Knowles had dementia care needs, which meant they might have difficulty engaging in complex conversations with us. We spent time in the lounges closely observing people’s experience. We looked at their mood, how they spent their time and how staff interacted with them.

We looked at three people’s care records. We spoke with the registered manager, the area operations director, administrator and two care staff. We looked at some records relating to the running of the home, such as the staff duty rota and training records.

We observed staff addressing people by their preferred names. Personal care was carried out in private and staff were discreet when asking about care needs. We observed some staff spending time talking and giving sensitive responses at a pace and level appropriate for the person.

We observed that people experienced care and treatment that met their needs, but care records were not always completed fully, or updated if people’s needs changed.

People spoken with told us they were generally satisfied with the care they received. Their comments included,

“I feel safe and happy here.”

“It’s very good. Everyone is very kind.”

We observed that people felt confident in approaching the staff and asking for support. We saw that people were treated respectfully. People told us they felt safe living here. The staff we spoke with knew what constituted abuse or neglect and knew what action they should take is they suspected it.

We found there were enough qualified, skilled and experienced staff to meet people’s needs.