- Care home
Knappe Cross Care Centre
We served a warning notice on Ashdown Care Limited on 24 January 2025 for failing to ensure their governance processes and systems were effective in the safe running of the service. Without these systems being effective, they could not be proactive in identifying issues and concerns and could not act on these in a timely way at Knappe Cross Care Centre.
Report from 6 November 2024 assessment
Contents
Ratings
Our view of the service
Knappe Cross Care Centre is registered to provide accommodation and nursing or personal care to up to 47 people. The service is a nursing home providing support to older people living with dementia. At the time of our visit there were 27 people living at the home.
We visited Knappe Cross Care Centre on 27 November 2024 and the 3 December 2024. This assessment was carried out due to concerns raised about safeguarding and poor care at the home. The service was in a local authority whole service safeguarding process. They were receiving support from the local authority quality assurance and improvement team and the eastern care services team as part of this process. The provider had implemented a service improvement plan setting out the actions being taken to address the concerns found during this process.
During our visits we carried out observations in the communal areas and speak with people, staff and visitors. We spoke with 7 people and 3 relatives, the provider’s operations manager, the new home manager, 12 staff and 2 agency nurses,
We found a continued breach of Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Governance systems and audits to monitor the quality of the service were not effective. When shortfalls had been identified, action had not been taken to make improvements and the shortfalls continued.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
The provider had made improvements since our last inspection in December 2022 and are no longer in breach of Regulation 12, Safe care and treatment (of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
At out last inspection, December 2022, the service was rated requires improvement. At this assessment, the service has remained requires improvement.
People's experience of this service
People told us they felt safe living at the service. They told us staff did a good job and supported them appropriately with their day-to-day needs. We observed staff to be kind and caring.
People told us it was sometimes difficult to understand staff whose first language was not English. The management team were looking at ways they could support these staff to improve their communication skills.
Relatives felt the risks to their family member were managed and when incidents happened these were investigated, and action taken to mitigate the risk of a further incident. Work was being undertaken to improve oversight of accidents and incidents.
People were supported by enough staff who had received the provider’s mandatory training, had been safely recruited to ensure people’s safety and meet their needs.
Improvements have been made to the way medicines were managed. People received them safely as prescribed for them.
Staff had completed the provider’s mandatory training. Improvements were needed in staff understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).
Risks to people were not always well managed. The provider’s management team had put in place a service improvement plan to address these concerns and were working with the local authority to address the concerns they found during the whole service safeguarding process.
The environment was predominantly safe, clean, tidy and mostly free from odours. However, people could have been placed at risk of harm because doors to areas of risk were not locked, a threadbare carpet was not made safe and the annual servicing of fire extinguishers had not been completed.
The provider had a quality assurance program, but this had not been effectively carried out, due to lack of leadership and clear direction. A new manager was working alongside staff providing support and supervision to identify concerns and to help shape the culture of the service.