Mentfade Limited Kynance Residential Home Inspection report Mentfade Limited 97 York Avenue East Cowes Isle of Wight PO32 6BP Tel: 01983297885 Date of inspection visit: 05 April 2018 10 April 2018 Date of publication: 17 May 2018 Ratings Overall rating for this service Good Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Good 1 Kynance Residential Home Inspection report 17 May 2018 Summary of findings Overall summary Kynance Residential Home is a 'care home'. People in care homes receive accommodation and nursing or 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 home is registered to provide accommodation for up to 32 people. There were 28 people living at the home at the time of the inspection. The home was based on two floors connected by a passenger lift, in addition to a basement where the kitchen and laundry are located. There was a good choice of communal spaces where people were able to socialise, including a conservatory that was used as the dining room. All bedrooms had en-suite facilities. The inspection was conducted on 5 and 10 April 2018 and was unannounced. There was a registered manager in place. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run. At our last inspection, in February 2017, we rated the service 'Requires improvement' and identified breaches of Regulations 9 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to protect people effectively from the risk of choking and had failed to ensure people's care needs were met in a personalised way. The provider wrote to us, detailing the action they would take to address the concerns. At this inspection, we found action had been taken to address all areas of concern and there were no longer any breaches of regulation. The management team had made significant improvements to a range of processes and procedures, making them tighter and more robust to help ensure people were supported consistently in a safe and personalised way. Three nutritional assistants had been appointed to support people to eat and drink safely and ensure their nutritional needs were met. This had helped people maintain a healthy weight. Other individual and environmental risks to people were managed effectively. Risk assessments had been developed for all identified risks and people were involved in risk taking decisions. People felt safe living at Kynance. Staff knew how to identify, prevent and report abuse. Safeguarding investigations were thorough and identified learning to help prevent a reoccurrence. There were enough staff to meet people's needs in a timely way. Appropriate recruitment procedures were 2 Kynance Residential Home Inspection report 17 May 2018 in place to help ensure only suitable staff were employed. Arrangements were in place for the safe management of medicines. People received their medicines as prescribed. The home was clean and staff followed best practice guidance to control the risk and spread of infection. People's needs were met by staff who were competent, trained and supported appropriately in their role. Staff acted in the best interests of people and followed legislation designed to protect people's rights and freedom. People described Kynance as homely. Some adaptations had been made to make the environment suitable for the people who lived there, including level access to an outside space. People were supported to access healthcare services when needed. Staff made information available to other healthcare providers to help ensure continuity of care. People were supported by kind, caring and compassionate staff. Staff made people feel they mattered by creating a family atmosphere and celebrating important events. They knew people well and supported people to maintain relationships that were important to them. Staff expressed a commitment to treating people according to their individual needs, wishes and preferences. They protected people's privacy and dignity. They encouraged people to remain as independent as possible and involved them in decisions about their care. People's needs were met in a personalised way. Each person had a care plan that was centred on their individual needs. Staff empowered people to make choices and responded promptly when people's needs or preferences changed. Staff worked in partnership with healthcare professionals to support people at the end of their lives to have a comfortable, dignified and pain-free death. People had access to a range of activities. They knew how to make a complaint and felt any concerns would be listened to and addressed effectively. People and their relatives felt the service was run well. Staff were organised, motivated and worked well as a team. There was a clear management structure in place and the registered manager had access to appropriate support. There were effective quality assurance systems in place. People were consulted about the way the service was run and staff acted on feedback provided. People described an open and transparent culture within the home, where they had ready access to the management and visitors were welcomed at any time. 3 Kynance Residential Home Inspection report 17 May 2018 The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? Good The service was safe. Individual and environmental risks to people were managed effectively. People were involved in risk-taking decisions to help them retain their independence. People felt safe and staff knew how to protect people from the risk of abuse. There were enough staff to meet people's needs and recruitment practices helped ensure only suitable staff were employed. Arrangements were in place for the safe management of medicines and people received their medicines as prescribed. There were appropriate systems in place to protect people by the prevention and control of infection. Is the service effective? Good The service was effective. People received effective care from staff who were competent, suitably trained and supported in their roles. People were supported to eat and drink enough, including through the use of dedicated nutritional assistants. Staff acted in the best interests of people and followed legislation designed to protect people's rights and freedom. Adaptations had been made to the environment to make it supportive of people who lived at Kynance. People had access to health professionals and specialists when needed. Procedures were in place to help ensure that people received consistent support if they were admitted to hospital. Is the service caring? The service was caring. 4 Kynance Residential Home Inspection report 17 May 2018 Good Staff treated people with kindness and compassion. They interacted positively with people and created a family atmosphere. Staff expressed a commitment to treating people according to their individual needs, wishes and preferences, including their specific communication needs. Staff understood the importance of protecting people's privacy and dignity. They promoted independence and involved people in decisions about their care. Is the service responsive? Good The service was responsive. Care and support were centred on the individual needs of each person. Care plans contained detailed information to enable staff to provide care and support in a highly personalised way. Staff responded promptly when people's needs or preferences changed. People were supported at the end of their lives to have a comfortable, dignified and pain-free death. People were empowered to make choices about all aspects of their lives. They had access to a range of activities suited to their individual interests. People knew how to raise a complaint and low level concerns were captured to help drive improvement. Is the service well-led? The service was well-led. People were happy living at the home and had confidence in the management. People, their families and staff felt engaged in the way the service was run and were consulted regularly. Staff were organised, motivated and worked well as a team. They felt supported and valued by their managers. A quality assurance process was in place to assess and monitor the service. 5 Kynance Residential Home Inspection report 17 May 2018 Good People described an open culture. Visitors were welcomed at any time and links had been developed with the community to the benefit of people. 6 Kynance Residential Home Inspection report 17 May 2018 Kynance Residential Home Detailed findings Background to this inspection We carried out this comprehensive inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. This inspection took place on 5 and 10 April 2018 and was unannounced. It was completed by one inspector and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. Before the inspection we reviewed all information we had received about the service, including previous inspection reports, the provider's action plan for improvement and notifications. Notifications are information about specific important events the service is legally required to send to us. During the inspection, we spoke with 11 people who use the service and four family members. We observed care and support being delivered in communal areas of the home. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with the registered manager, the two deputy managers, six care staff, two nutritional assistants, a cook and a housekeeper. We also received feedback from two health and social care professionals who had contact with the service. We looked at care plans and associated records for six people and records relating to the management of the service, including: duty rosters, staff recruitment files, accident and incident records, maintenance records and quality assurance records. 7 Kynance Residential Home Inspection report 17 May 2018 Good Is the service safe? Our findings At our last inspection, in February 2017, we identified a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to protect people effectively from the risk of choking. At this inspection, we found action had been taken and there was no longer a breach of this regulation. Three nutritional assistants had been appointed to support people to eat and drink. When we spoke with them, we found they knew which people were at risk of choking and knew how to support them safely. This included making sure that, where needed, people's drinks were thickened to an appropriate consistency. Other staff were also aware of this need, but the use of dedicated nutritional assistants helped ensure this was done consistently well. Other individual risks to people were also managed effectively. Risk assessments had been completed for all identified risks, together with action staff needed to take to reduce the risks. For example, some people were at risk of developing pressure injuries and we saw special pressure-relieving mattresses had been provided. Staff knew how to adjust the mattresses and there was a clear process in place to help ensure they remained at the right setting according to the person's weight. When people experienced falls, their risk assessments were reviewed and additional measures considered to keep them safe. As a result of one review, we saw the person had been provided with bed rails to reduce the risk of them falling of bed. If people sustained a head injury, staff sought immediate medical advice and monitored the person closely to check for signs of brain injury. The registered manager reviewed all falls in the home on a monthly basis to identify any patterns or trends; none had been identified, but they described the action they would take if a common theme emerged. Staff had been trained to administer first aid and hosted an automatic external defibrillator (AED), on behalf of the local community, to treat sudden cardiac arrest. People were involved in risk-taking decisions to help them retain their independence and avoid unnecessary restrictions. For example, a person who was at risk of developing pressure injuries told us they had chosen not to use a pressure-relieving cushion on their chair. They told us, "I was given one [a pressure cushion], but I find it more comfortable with the normal cushion, so I don't use it." The person had capacity to assess the level of risk and had chosen to accept the risk. Another person had chosen to receive a normal diet, contrary to advice from a speech and language therapist. Staff told us they monitored the person closely, because of the increased risk of choking, but respected the person's decision. Environmental risks were managed effectively. Gas and electrical appliances were serviced routinely and fire safety systems were checked regularly. Staff were clear about what to do in the event of a fire. Each person had a personal emergency evacuation plan detailing the support they would need if the building needed to be evacuated and staff had recently completed an evacuation drill. In addition, reciprocal arrangements had been made to use neighbouring care homes in an emergency and to call in additional staff to support people. 8 Kynance Residential Home Inspection report 17 May 2018 On the first day of the inspection, we found a wedge was being used to hold one person's bedroom door open and some fire doors did not close properly, having been recently painted. We raised these concerns with one of the deputy managers and by the end of the inspection an electronic door release device had been fitted to the person's door and the newly painted doors were being adjusted to ensure they closed properly. People felt safe living at Kynance. One person told us, "I feel safe living in this home with good staff to support me." Another person said, "It is a safe place to live with staff who look after my needs." A family member told us, "I am happy that [my relative] is in a safe place with lots of care." Staff had the knowledge and confidence to identify safeguarding concerns and acted on these to keep people safe. They told us they would have no hesitation reporting concerns to any of the managers and were aware of external organisations, including CQC, they could go to for support. When people moved to the home, photographs were taken of their jewellery and valuables. This helped safeguard the person's property and enabled staff to reunite found property with its owner, thereby protecting the person from the risk of abuse. Where safeguarding concerns had been raised, we saw the registered manager had conducted thorough investigations and identified learning to help prevent similar concerns being raised in the future. Appropriate recruitment procedures were in place and followed. These included pre-employment reference checks and checks with the disclosure and barring service (DBS). The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services. Staff confirmed these processes were followed before they started working at the home. One staff member had recently worked for three care providers and references had been sought from each of them. Another staff had worked for three care providers in the past year, but a reference had only been sought from the most recent employer. Therefore, the provider was unable to confirm the staff member's reason for leaving, or their conduct at, the other two services. We raised this with the registered manager, who amended their recruitment processes to help ensure these additional checks were conducted in future. There were enough staff deployed to meet people's needs. One person told us, "Staff are always there for us and come quickly when I need them." Another said, "I can get hold of staff pretty quickly if needed." Throughout the inspection, we saw staff were available to support people and call bells were responded to promptly. One person told us, "They [staff] come quickly when I press my buzzer and there's always two staff if I need to use the hoist to go to [the bathroom]." The registered manager assessed staffing needs by observing staff and listening to feedback from people and staff. In response to feedback, they had recently increased the staffing levels between 6:00am and 8:00am to accommodate an increasing number of people who preferred to get up early. People were supported to receive their medicines safely and as prescribed. One person told us, "Staff look after my medicines and I always get them when I need them." A family member said, "They [staff] have managed to change most of [my relative's] medicines to a liquid form due to swallowing problems." There were clear processes in place to obtain, store, administer, record and dispose of medicines. Medicines were only administered by suitably trained, senior staff, who had their competence to administer medicines assessed every six months. Since the last inspection, staff had started wearing a red tabard with the words 'Do not disturb' written on it, to reduce the risk of them being interrupted while administering medicines. Staff told us this was working well. One person was taking Warfarin, a blood-thinning medicine; we saw a risk assessment had been completed to reflect the increased risk of bleeding if the person sustained an injury. One of the deputy managers told us they were in the process of extending these risk assessments to include other blood-thinning medicines that 9 Kynance Residential Home Inspection report 17 May 2018 people were prescribed. There was a clear process in place to help ensure topical creams were not used beyond the manufacturers' 'use by' date. Staff recorded the application of creams to people, although when several creams were prescribed to a person, the records did not specify which of the creams they had applied. We discussed this with the deputy manager, who amended the record sheets to allow staff to do this in future. There were appropriate systems, policies and procedures in place to protect people by the prevention and control of infection. These included infection control risk assessments, cleaning schedules and regular audits. All areas of the home were clean and staff completed cleaning check sheets to confirm that cleaning had been completed to the required standard and frequency. People commented that the home was always "clean and tidy", including one person who said, "My room always looks nice and clean." Staff had attended infection control training. They had access to personal protective equipment (PPE) and wore this whenever appropriate. They described how they processed soiled linen, using special bags that could be put straight into the washing machine to avoid the risk of cross contamination. A clear system was in place in the laundry room to help prevent cross contamination between soiled linen entering the laundry and clean linen leaving the laundry. One person had a suspected infection on the first day of the inspection and we saw staff were supporting the person in their room to avoid the risk of them spreading infection further. 10 Kynance Residential Home Inspection report 17 May 2018 Good Is the service effective? Our findings At our last inspection, in February 2017, we identified a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to ensure people's care needs were always met in an effective and personalised way. At this inspection, we found action had been taken and there was no longer a breach of this regulation. People consistently told us they received effective care from experienced and competent staff. Comments included: "This is a very good home with good support"; "Staff do a very good job of looking after me"; and "Staff here have both the time and training to look after and understand my needs". Family members echoed these comments, including one who told us, "Staff are all very good and well trained." New staff completed an effective induction into their role. This included time spent shadowing, (working alongside experienced staff) until they felt confident they could meet people's needs. Staff who were new to care work were supported to complete training that followed the standards of the Care Certificate. The Care Certificate is an identified set of standards that health and social care staff adhere to in their daily working life. Experienced staff received regular training in all key subjects and were supported to gain vocational qualifications relevant to their role. For example, a senior staff member was being supported to complete a level five management qualification. The provider had developed links with an occupational therapy specialist who provided face to face training in the use of equipment and supporting people to move. In addition, where needed, they provided advice about people's individual moving and repositioning needs to help staff support people in an effective and personalised way. Staff demonstrated an understanding of the training they had received and how to apply it. For example, the used moving and positioning equipment in line with best practice guidance. When communicating with people living with dementia, they used short, simple questions, remained calm and gave people time to respond. Staff told us they felt supported in their roles. Comments from staff included: "If I need to talk, I can always go the office any time"; "I'm very happy here and feel well supported. [The registered manager] managed to get me onto a level three course when [previous providers] hadn't even offered it"; and "[The registered manager] listens. We can discuss any issues". New staff benefitted from working with a staff mentor to help them understand their role in the first few weeks. This provided them with consistent support to a set standard. In addition, each care staff member had six one-to-one sessions of supervision with a senior staff member to discuss their progress and any concerns. Each session focused on a particular theme relevant to the staff member's role, such as infection control or dealing with blood spillages to help enhance staff understanding of key issues. The registered manager was in the process of completing annual appraisals with care staff where they discussed their performance and development needs. They told us they planned to extend this process to non-care staff over the coming year. 11 Kynance Residential Home Inspection report 17 May 2018 People's nutrition and hydration needs were met. One person told us, "The food is very good with plenty to eat and drink and I can always ask for more if needed." Another person described the food was "nicely produced". Each person had a nutritional assessment to help identify their dietary needs and preferences. They were offered a choice of suitable food at each meal; for example, people with diet-controlled diabetes were offered low sugar options. When people did not want any of the menu options, they were offered alternatives instead. If people did not eat their chosen meal, staff tempted them with alternatives, such as sandwiches and snacks. Snacks were also available and prominently advertised to people in the main lounge. Staff monitored people's weight and took action if they started to lose unplanned weight. Since the last inspection, the provider had recruited three 'nutritional assistants' to support people with complex needs to eat and drink well. They were used to support people to eat on a one-to-one basis and to prepare thickened drinks for people with swallowing problems. They also made sure everyone had access to fresh water and a variety of other drinks throughout the day. We spoke with two of the nutritional assistants and found they had a thorough understanding of people's individual needs and how to meet them effectively. One of them told us, "People need a lot of patience and time, especially [one person] who gets anxious. I love doing it." The introduction of nutritional assistants had resulted in fewer people losing weight and some gaining weight, which demonstrated the value of their role. However, we found the service of food was not always conducive to making meal times a social occasion. Although people were sat at tables in small groups, meals arrived at random times. This meant one person at a table would receive and eat their meal before others at the same table received theirs. The person who had finished their main course was then given a dessert, while others at the table were still eating their main courses. We discussed this with the registered manager who said they would explore ways to address this anomaly. Staff followed the principles of the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any decisions made on their behalf must be in their best interests and as least restrictive as possible. We found assessments of people's capacity had been made where needed, together with best interest decisions made in consultation with people's representatives. Where people had capacity, they had signed their care plans to indicate their agreement to the care and support they received. Furthermore, staff sought verbal consent from people before providing any care or support. One person told us, "Staff always check and ask before doing anything." People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. We found staff were following the necessary requirements. One DoLS authorisation had expired and was awaiting renewal by the local authority. Other new applications were also awaiting assessment by the local authority. The care plans for people awaiting assessment had been marked with a sticker, to make staff aware. However, when we spoke with staff, they thought the stickers indicated that a DoLS had already been authorised, which was not the case. This posed a risk that people might be deprived of their liberty without legal authorisation. We raised this with one of the deputy managers, who took immediate action to clarify the situation with staff. 12 Kynance Residential Home Inspection report 17 May 2018 People described the environment as "homely". Their bedrooms had been decorated to their tastes, together with some of their furniture and important possessions. One person told us, "Look at my new curtains and [matching] duvet cover. They [staff] got these specially for me and they adjust [the curtains] so the sun doesn't get in my eyes. They are very good." Adaptations had been made to the home to make it as supportive as possible for the people who lived there. Handrails in contrasting colours provided support to people in communal areas. Most floor coverings had also been replaced and a decorating programme was underway to further enhance the environment. People had access to a quiet lounge or a busy lounge connected to a conservatory. Staff monitored the temperature in the conservatory and offered to open doors for people if it became too warm. There was also level access to an outside area of decking that people said they enjoyed when the weather was warm and staff told us extra parasols had been purchased to protect people from the sun when using the area. Some signs helped people to navigate their way around the home, for example to find the bathrooms, although these were limited and people's bedroom doors were not prominently signed to support them to find their rooms. The registered manager told us they had not completed an environmental audit to assess whether the home was supportive of people living there, but had visited a specialist dementia home to pick up ideas and was considering the options. People were supported to access healthcare services when needed. One person told us, "I saw a doctor about my diabetes. They said I don't need regular blood sugar checks now, so I don't have unless I need them." A community nurse who had regular contact with the home told us they enjoyed positive relationships with staff at Kynance. They said, "We like the home. Staff are good and always available. They report [concerns] correctly and call us early." They added that staff always followed any recommendations they made. Care records confirmed that people were seen regularly by doctors, specialist nurses and chiropodists. They were supported to attend medical appointments and procedures were in place to help ensure that people received consistent support if they were admitted to hospital. Staff made appropriate use of technology to support people. For example, pressure mats were used to alert staff of the need to support people when they moved to unsafe positions. Special pressure-relieving mattresses had been installed to support people at risk of pressure injuries and an electronic call bell system allowed people to call for assistance when needed. Wi-Fi had also been installed to allow people or their visitors to connect to the internet and to allow staff to access training resources online. 13 Kynance Residential Home Inspection report 17 May 2018 Good Is the service caring? Our findings People were supported by kind, caring and compassionate staff. Everyone we met spoke positively about the attitude and approach of staff. Comments from people included: "I am really well treated in this home and it is a friendly and happy place to live"; "Staff make you feel like you matter"; "They are very cheerful and laugh a lot"; and "The staff are kind". Family members echoed these views, including one who told us, "[My relative] is treated with kindness and compassion and has got to know staff quite well." A thank-you card sent to staff from another family member stated: "Your care, kindness, thoughtfulness and love toward [our relative] was second to none. You are all special." Staff made people feel they mattered by creating a family atmosphere and celebrating important events. Three people told us that living at Kynance was like "being part of a big family". One person added, "The atmosphere at the home is very good with caring and friendly staff." A family member told us, "Christmas time [in particular] is great fun with lots of presents and staff will bring in young children." An email from another family member thanked staff for the care being provided to their relative and added: "I was talking to [my relative] by phone on their birthday when a carer, singing Happy Birthday, gave her a bouquet of flowers from the staff. [My relative] was delighted and I felt very touched at such kindness. Later in the day, she also enjoyed a Kynance birthday cake." Staff supported people to build and maintain relationships that were important to them. A family member told us, "It was a huge adjustment for [my relative] to move from living independently in her own home and I am pleased to hear she is beginning to socialise with two or three other residents." Staff repeatedly talked with people about their family and friends outside the home. For example, on arriving for work a staff member told a person, "I've just seen [your relative] in town doing some shopping. He sends his love and says he'll be up later." A staff member told us, "This is people's home and we need to create a happy atmosphere." Another staff member said, "It's a happy home with good relationships and friendships going on. We try and match people up and get them playing games together, especially when they're new." "We have a good bond with residents. There's good banter all day long." Our observations confirmed this. People and staff clearly knew each other well and we heard relaxed laughter and friendly banter throughout the two days of our inspection. Without exception, all interactions we observed between people and staff were positive and supportive. Staff engaged with people, checked they were comfortable, bent down to their level and used touch appropriately to reassure. When a person returned from a hospital visit, staff welcomed them back warmly, asked how it had gone and offered them a drink. When a person vocalised their anxiety while mobilising, staff remained calm, gave patient reassurance and praised the person once they had completed the manoeuvre. When another person became upset, a staff member sat and held their hand until they felt brighter; they then offered to call the person family because "they always bring a smile to your face". All staff expressed a commitment to treating people according to their individual needs, wishes and 14 Kynance Residential Home Inspection report 17 May 2018 preferences. One person was mainly vegetarian, but had asked to be offered the full choice from the menu and we heard this being done; this demonstrated respect for the person's wishes. Where people had specific communication needs, these were recorded in their care plans and known to staff. Staff had developed positive working relationships with a hearing loss charity that was supporting one person. Another person with hearing loss told us, "I use subtitles on TV; they [staff] put them on especially for me." A further person had poor eyesight, so a large button telephone had been installed in their room. A staff member told us, "Communication is important and you have to go at their speed; don't rush anyone. When people are unable to communicate [due to cognitive impairment], we try and gather as much information from families about [the person's] preferences. For example, [one person] can't say what they want to wear, but we know from the family that they always liked to be dressed smartly with a blouse and a scarf, so that's what we do." Staff understood the importance of protecting people's privacy and dignity. A family member told us, "[My relative] is treated with dignity and respect." A visiting healthcare professional told us, "People's privacy is protected. I'm very happy with the place." Staff took care to look after people's property and keep their rooms tidy; for example, people's clothes were hung neatly in wardrobes or carefully folded in drawers. People confirmed that staff considered their privacy when providing personal care by closing doors and curtains. A staff member told us, "We shut doors and wash one half [of the person] at a time, so they're never completely naked." Some people had asked to receive personal care from female staff only and they confirmed this wish was always respected. Staff respected and promoted independence by encouraging people to do as much as possible for themselves. One person told us, "I feel free and easy to get on with my life." Another person said, "I'm left to my own devices, but they [staff] come in when I want them." A family member commented, "[My relative] can get up and go to bed when she likes and there are no restrictions on her movements." People's care plans also encouraged staff to promote independence. For example, the care plan for one person noted they were unable to reach the clothes in their wardrobe, but directed staff to give the person the option and the time to choose their clothes for the day. People and relatives told us they were involved in discussing the support they wished to receive. A family member told us, "I can see [my relative's] care plan if I want to and one of the managers always keeps me up to date. For example, they let me know about a [hospital] appointment." Information in people's care records confirmed that they, and family members where appropriate, were consistently involved in developing and reviewing their care plans. During pre-admission assessments, managers explored people's faith needs and staff supported people to follow their faith. Most people living at the home were of one particular faith and a service was held regularly for them. In addition, one person received Holy Communion from a visiting member of their church. The registered manager told us they explored other aspects of people's cultural and diversity needs during ongoing discussions with people about their backgrounds, interests and beliefs. 15 Kynance Residential Home Inspection report 17 May 2018 Good Is the service responsive? Our findings The service was responsive to people's needs. Staff provided flexible and individualised care and support to people. One person told us, "Staff are all nice and supportive of my needs." Another said, "Staff know my needs and requirements." Comments from family members included: "The home is very responsive to the care and support of [my relative]" and "[My relative] is happy with all the arrangements for getting up and going to bed. She has a good routine." Care and support were centred on the individual needs of each person. Assessments of people's needs were completed by one of the managers, before people moved to the home. This information was then used to develop an appropriate care plan in consultation with the person and their relatives where appropriate. Care plans contained detailed information to enable staff to provide care and support in a highly personalised way according to people's individual needs. They included people's normal daily routines, their backgrounds, hobbies, interests and personal preferences, for example how and where they wished to receive personal care. Staff told us they found the information within the care plans useful and that it helped them understand the person and their needs. They demonstrated a good awareness of the individual support needs of each person living at Kynance, including those living with dementia. They knew how each person preferred to receive care and support; for example, which people needed to be encouraged to drink; the support each person needed with their continence; and where people liked to spend their day. Staff also recognised that some people's mobility varied from day to day and were able to assess and accommodate the level of support they needed at a particular time. One staff member told us, "The care plans are easier to follow now. The risk flags are helpful and all the information [needed to support each person] is available." Another staff member said, "We treat everyone according to their needs individually. It's all down to communication and [knowing] what each person wants; for example, some people like to brush their teeth before they wash and vice versa; some like their legs creamed when sat in a chair, some when they're laid on the bed. It's to do with that person and meeting what they want." Staff responded promptly when people's needs or preferences changed. A family member told us, "They [staff] are quick at spotting changes and let me know." A staff member told us, "It's nice working with [people] as individuals as you can spot when they're not well. For example, [one person] is not himself today, so I've flagged it up to a senior [staff member] to monitor." Staff had noted that more people wanted to get up early, so had adjusted their shift times to accommodate this. One staff member told us, "We have more early risers now. I think they feel safer around people in the lounge than they do in their rooms. [One person] will get up very early, but will then have some toast and go back to bed." This demonstrated that staff worked flexibly to support people's wishes and preferences. Records of the daily care provided confirmed that people had been supported in accordance with their 16 Kynance Residential Home Inspection report 17 May 2018 identified needs. For example, one person needed catheter care and received this consistently. Catheters are devices used to drain a person's bladder through a flexible tube linked to an external bag. Staff monitored and recorded the output from the person's catheter to check it was working effectively, changed the bags regularly and sought advice from community nurses when there were any changes or concerns. Another person needed to be supported to reposition in bed and turning charts confirmed this was done regularly. People were supported at the end of their lives to have a comfortable, dignified and pain-free death. This was confirmed by a letter from the family member of a person who had recently died at Kynance. It said, "Thank you for giving [my relative] the wonderful care you all gave her over the past three years and for the love, care and attention she received for the last few days of her life. Can't thank you all enough." Most staff had completed end of life training delivered by a local hospice. They had experience in delivering end of life care and described important aspects, including maintaining the person's dignity, managing any pain, ensuring their comfort and supporting family members. Staff told us they enjoyed positive working relationships with the local doctors and community nurses. They said this helped them advocate for people and ensure they had access to anticipatory medicines to manage their symptoms. Although some information about people's end of life wishes was recorded in their care plans, this was limited; however, one of the deputy managers told us they were exploring ways to gather and record this information more consistently, to help ensure people's end of life wishes were always known and followed. Staff promoted choice and respected people's autonomy by empowering them to make as many of their own decisions as possible. We heard people being offered choices throughout the inspection. For example, one person was supported to move to the conservatory as staff knew they "enjoyed the sun". Once there, they were asked if they wanted to "face outwards towards the park of inwards towards the lounge". Another person usually liked to stay in their room but told us they "liked to be given the choice to go downstairs". This preference was recorded in their care plan and we later heard staff offering the person the option of going downstairs. A staff member told us, "If people struggle to choose their clothes [due to cognitive impairment], we would get a choice of two [sets of clothes] and they would point or smile to choose one." People had access to a range of activities. These were advertised on the home's notice board and people were encouraged to take part. They included chair exercises, bingo, singing, crafts and board games. One person told us, "There are plenty of activities and things to do." Another person was proudly wearing an Easter bonnet they had made during a craft activity. They told us, "It's lovely and I've never made a hat before." A family member told us, "[My relative] is happy spending time in the lounge taking part in activities. She loves all that." People who did not wish to take part in group activities were offered one-to-one activities with staff on an occasional basis, including with a volunteer who supported people with activities every other weekend. There was a complaints procedure in place, which was advertised on the home's notice board. People and family members said they knew how to complain about the service but had not had cause to. One family member told us. "I've never needed to raise a complaint or concerns over how the home is being run or how [my relative] is being treated." People felt the managers were approachable and that any concerns would be listened to and addressed effectively. No formal complaints had been recorded in the previous year. However, managers had started recording low-level concerns in a 'You said, we did' format to help drive improvement. For example, one person had commented that the soup was not always hot and this had been addressed with kitchen staff. This demonstrated how the service listened to, and acted on, feedback from people. 17 Kynance Residential Home Inspection report 17 May 2018 Good Is the service well-led? Our findings People were happy living at Kynance and felt the service was well-led. Comments from people included: "I like it here, I would not want to move"; "The home is a very good place to live due to the staff and how the home is run"; and "Staff are well organised. I'm happy to recommend this home to anyone looking for help or support". Family members echoed these comments; for example one told us, "We know the management very well and we're very thankful for the support they've given me and [my relative]." Since the last inspection, the management team had made significant improvements to a range of processes and procedures, making them tighter and more robust to help ensure staff were supported to follow best practice guidance consistently. These included enhanced procedures for supporting people to eat safely, supporting people's diabetes care needs and supporting people at risk of pressure injuries. Clear flow charts had been produced, to help staff know when to take action and what action to take. These included guidance for dealing with hypoglycaemia (low blood sugar levels) and serious injuries. Some people's care plans had also been marked with different coloured spines to highlight specific risks relevant to the person, including choking risks and risks posed by certain medicines. There was a clear management structure in place consisting of the registered manager, two deputy managers and senior care staff. Each had clear roles and responsibilities and the management team worked well together. In addition, an 'on call' rota was in place to enable staff to access management advice out of hours. Staff told us they felt engaged in the way the service was run. They said the registered manager operated an "open door" policy and held regular staff meetings to seek feedback and keep them up to date. In addition, arrangements were in place to help staff communicate effectively with one another. For example, staff kept a nutrition folder to highlight changes in people's nutritional needs and the support they needed as a consequence. Staff told us they were happy, motivated and worked well as a team. Comments included: "I'm happy in my work"; "I am very happy here and feel well supported"; and "it's a happy, well-run home. There's good morale and we all get on well". We found staff were organised and completed delegated tasks in an efficient and effective way, ensuring all the work got done at a relaxed pace. The registered manager told us they felt supported by the provider, who visited most days. When we spoke with the main director of the provider's company, they expressed full confidence and trust in the competence, experience and ability of the registered manager with whom they enjoyed a positive working relationship. The registered manager and one of the deputy managers had recently attended a five day course for home managers, commissioned by the local authority. They spoke positively about the course, including the opportunity to meet other home managers to share ideas and examples of best practice. Following the inspection, the registered manager sent us a 'Quality improvement plan' using a format they had learnt on the course. This clearly sets out action they intend to take to further enhance the quality of service and to address the minor improvement issues identified in this report. 18 Kynance Residential Home Inspection report 17 May 2018 There were effective quality assurance systems in place. These were based on a wide range of regular audits, including infection control, medicines, care plans and the environment. When improvements were identified, action was taken. For example, the infection control audit identified a need for additional cleaning in one area and we saw this had been done. New checks of pressure-relieving mattresses had been introduced and these had helped ensure all mattresses were set correctly. Information from incidents and investigations was used to drive improvement in the service. For example, following a medicine error, additional audits of medicines had been introduced, together with a more structured approach to assessing the competence of staff who administered medicines. These improvements had reduced the likelihood and potential impact of further medicine errors. People were consulted in a range of ways about the way the service was run. These included regular "residents meetings", yearly questionnaire surveys and individual discussions with people and their relatives. In addition, we saw a comments box had recently been installed in the hallway to enable people to provide feedback anonymously if they wished. Any issues raised were acted on promptly. For example, some people had asked for more snacks to be made available in the evening and we saw a box of assorted snacks had been put in the lounge for people to access at any time. People and relatives described an open and transparent culture within the home, where they had ready access to the management. Visitors were welcomed at any time. The provider notified CQC of all significant events and the home's previous inspection rating was displayed prominently in the entrance hall. In addition, the results of the latest survey of people and their relatives were displayed on the notice board. Duty of candour requirements were being followed; these required staff to act in an open and transparent way when accidents occurred. The registered manager showed us examples of where they had provided information in writing to family members, as required and family members confirmed that they were always notified when their relative had an accident. Positive links had been developed with the community, including with local churches, schools and charities, including one charity that supported people with hearing loss and another that supported blind veterans. The registered manager had developed a vision and a set of values for staff to follow. These included putting people and their individual needs first, supporting people to achieve their aspirations, being honest and transparent, learning when things go wrong and celebrating success. The values were discussed and communicated to staff at staff meetings and the registered manager was planning further work to fully embed them in working practices. Our observations confirmed that staff understood these values. When we spoke with them, they demonstrated a shared commitment to supporting people in a person-centred way and to the best of their abilities. 19 Kynance Residential Home Inspection report 17 May 2018