We inspected Little Trefewha on 15 October 2018.The inspection was unannounced. The service is for elderly people, some of whom may have physical disabilities or mild dementia. At the last inspection, in December 2017, the service was rated as 'Requires Improvement.' This was because we judged the service did not have a satisfactory system to monitor and improve some aspects of the quality of the service. As a result we issued a statutory requirement about the need to improve the assessment and monitoring of the quality and safety of the care the service provided. After that inspection the registered persons sent us an action plan detailing how they were going to make improvements so they complied with the regulations.

At this inspection we found that, on the whole, satisfactory action had been taken, although we still had concerns about staff recruitment checks. As a consequence, we have issued the service with a statutory requirement to improve recruitment checks and this has had an overall impact on the rating of the service, although other aspects of the service are seen as good, and people were happy with the care they received.

Little Trefewha is a 'care home'. 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. Little Trefewha accommodated up to 21 people, and there were no vacancies at the time of the inspection.

The service had 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 service was viewed by people we spoke with as very caring. We received positive comments about the service. For example, we were told, "Nothing is too much trouble for the staff," and "They are always doing something to make you more comfortable. " A relative told us said, "I find this home wonderful, and a staff member said, "Residents always come first," and "Care is very good. Everyone works to the best of their ability. When we raise concerns they are dealt with." Everyone we saw looked well cared for. People were clean and well dressed. The service provided some activities.

People told us they felt safe. For example, one person told us, "I feel safe because the staff are very friendly to me." The service had a suitable safeguarding policy, and staff had been appropriately trained to recognise and respond to signs of abuse.

People had suitable risk assessments to ensure any risks of them coming to harm were minimised, and these were regularly reviewed. Health and safety checks on the premises and equipment were carried out appropriately.

There were enough staff on duty to meet people's needs. Although we had no concerns about the conduct of any staff member we were concerned about recruitment procedures for staff members. For example, an employment history was not always given on staff application forms, and references were not always taken up from the candidates most recent employer and when they have not recently worked in a caring capacity.

Staff members received an induction. However, there was no record that some staff, who had not worked in health or social care, had commenced or completed the Care Certificate. This is a set of national standards for staff coming into the health and social care sector. Although there was a record all staff had received an induction, we have made recommendation that staff without recent care experience complete the Care Certificate. Overall staff had received suitable training. However, some staff members did have gaps in the receipt of training, for example about adult safeguarding, first aid and dementia.

The medici

This unannounced comprehensive inspection took place on 18 December 2017. The last inspection took place on in November 2015 when the service was meeting the legal requirements. The service was rated Good at that time.

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. Little Trefewha is a care home which offers care and support for up to 21 predominantly older people. At the time of the inspection there were 20 people living at the service. A few of these people were living with dementia. The service occupies a detached house with two floors. There was a stair lift to assist people to the upper floors.

The systems in place for the management and administration of medicines was not entirely safe. The service used medicines that required stricter controls. The records of these medicines did not tally with the stock held at the service. Staff had handwritten medicines on to the Medicine Administration Records (MAR) but staff had not followed their own medicine policy guidance and these entries had not been signed and witnessed by two staff. This did not protect people from the risk of potential errors being made. There were many gaps in the MAR where staff had not signed to indicate if people had been given their medicines at the prescribed times. This meant it was not possible to establish if people always received their medicines as prescribed. Prescribed creams were not dated when opened. This meant staff were not aware when the item should be disposed of as no longer suitable to be used. Some people were self administering their own medicines. Two people did not have appropriate secure storage for their medicines in their bedrooms. Some medicine audits were being carried out and gaps in MAR charts had been identified as a concern in a number of audits. However, there was no evidence that effective action had been taken to help ensure that future events were reduced. No audits were being carried out regarding medicines that required stricter controls. The concerns found with the medicines management at the service had not been identified prior to this inspection.

Fire doors to five rooms were found held open with wedges and ornamental door stops. The provider took immediate action to address the concerns found at this inspection. The door guard devices fitted to two bedroom fire doors were replaced during this inspection as they were not functioning correctly. A number of door guards were not effectively holding the fire doors open due to not having appropriate plates screwed through the carpeting to enable to door guard to hold open safely and securely. This had led to the door guards slipping on the carpeting and closing when people wished their doors to be open. Door wedges had been used by staff to hold doors open. This meant these fire doors would not close in the event of the fire alarm being activated and placed people at risk. We have made a recommendation in this regard in the Safe section of this report.

Staff were not provided with supervision and annual appraisals according to the policy held by the service. However, there were regular staff meetings and staff were able to access informal support whenever needed. Recruitment of new staff was not always robust. Four out of six staff files reviewed only had one reference taken up by the service before the person began to work at the service. This was not in line with the service recruitment policy.

One person had been identified as being at risk of dehydration. The recording of this person’s fluid intake was not always appropriately completed by staff. No totalling or monitoring of these records were evidenced. This meant it was not possible for staff to judge if the person had had sufficient drinks each day.

Audits and checks of the service provided which were carried out, were not

At our last inspection 5th November 2013 we had concerns in two outcome areas and set compliance actions. The provider sent us an action plan informing us how Little Trefewha was addressing the issues raised in the last report. We carried out this inspection to review the compliance actions set. At the time of this inspection we were told there were 21 people living at Little Trefewha, however, we were told one person was currently unwell and in hospital.

We spoke with the provider, the registered manager, two staff and five people who lived at the home. Their comments were mostly postiive and included "the staff are lovely, so kind", "the food is very good" and "we are all just one team". One person told us they felt too anxious to spend time in the lounge area as "I could not get staff to help me to go to the toilet when I needed to go, I had to ask the other people in the lounge to call them, they asked why I needed them (staff), then everyone knew what I wanted, it was embarrassing, so I stay in my room now".

We found the provider sought the views and experiences of the people who lived at Little Trefewha through resident's meetings and in one to one discusssions. People we spoke with felt they could approach the registered manager at any time.

We found the provider had an effective system in place to assess and monitor the service which was provided to people at Little Trefewha.

We spoke with the registered manager, five staff, and six people who lived at Little Trefewha. Their comments were all positive and included “it is home from home”, “lovely here” and “no fault at all with any of them”.

At the time of our inspection there were twenty people living at Little Trefewha. We spent time observing people and staff during the day. We saw staff knock on people’s bedroom doors and wait for an answer before entering, and sought people’s permission before providing care and support. We witnessed staff interactions with people which were positive.

We found people’s views and experiences had not always been recorded and taken into account in the way the service was provided and delivered in relation to their care.

We saw people’s privacy and dignity was respected, and staff were helpful.

People were protected from the risks of inadequate nutrition and dehydration.

We found people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Staff had received appropriate training and supervision.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. Staff records were not being effectively monitored.

People we spoke with were complimentary about the service they received and the staff. People felt they could approach staff or the manager with any questions or concerns. Comments made included “This is the place to be”, “The food is good old fashioned food, like we would have made for ourselves”.

We saw staff knock on people’s bedroom doors and wait for an answer before entering, which showed people’s privacy and dignity was respected. People who used the service said they were able to express preferences and make meaningful choices. For example, people chose when they got up in the morning, where they spent their day, and what they wanted to eat. People’s likes and dislikes were known. We saw staff talk with people and observed that they were respectful, friendly and supportive of them. The atmosphere in the home was warm, welcoming and there was a sense of fun.

We spoke to an external professional who said “it’s a really good home”.

From our inspection we found that people experienced care, treatment and support that met their needs and protected their rights.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People who used the service, their representatives and staff were asked for their views about their care and treatment, and they were acted on.

We reviewed all the information we hold about this provider, carried out a visit on 17 January 2012, observed how people were being cared for, talked with people who use services, talked with staff, and checked records.

People we spoke to were complimentary about the service they receive and the staff. People we spoke with said they couldn’t praise the home highly enough and they felt they could approach staff with any questions or concerns. All said they had confidence in the registered manager. We saw people’s privacy and dignity being respected and staff being helpful. There were no issues raised by people who used the service or by staff. People who use the service were moving freely around the home.

Staff told us they liked working at the home, and they confirmed the availability of training courses and staff supervision. Staff told us they had confidence in the registered manager.

Little Trefewha is a care home which provides accommodation for up to 21 older people who require accommodation and personal care. At the time of the inspection 18 people were using the service. Some people also had physical or sensory disabilities.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

We inspected Little Trefewha Care Home on 17 and 18 November 2015. The inspection was unannounced. The inspection date was brought forward as we received information about concerns in relation to the service. However our inspection found people were cared for, and the service was managed appropriately.

The service was last inspected in January 2014 and was found to be meeting the requirements of the regulations.

People told us they felt safe at the service and with the staff who supported them. People told us, “It is very, very, very good. That is all I can say,” “It is a home from home,” and “It is lovely, brilliant; It couldn’t be better.” Staff were also positive about their experiences of working at the service. For example we were told “(It is) the happiest I have ever been in a workplace…everyone pulls together,” and “We have a very good reputation. We work well together.”

According to records staff had received appropriate training, and had been suitably trained to recognise potential signs of abuse and subsequently take suitable action. Recruitment processes were satisfactory. For example there was a satisfactory recruitment process, pre-employment checks such as references had been obtained. A Disclosure and Barring Service (DBS) check had been obtained for all staff members to ensure there were no police or other public authority information to state the person was unsuitable to work in a caring capacity.

People said they received their medicines on time, and we judged the medicines system was well managed. People had access to a general practitioner, and other medical professionals such as a dentist, chiropodist and an optician. GP records were thorough but some records, for example, about input from dentists was variable. This made it difficult to check whether people wanted or needed to see practitioners such as a dentist.

Staffing levels were judged as satisfactory. People, and most staff who worked at the service, said there were enough staff provided although some staff said at times staffing levels could be tight for example if some people were unwell.

People who used the service told us staff were caring, worked in a respectful manner and did not rush them. For example people said, “The carers are 100% day and night “, and “(It is) wonderful I could not say anything else…they are happy staff and very obliging.” People said they could spend their time how they wanted, were provided with a range of choices, and were able to spend time in private if they wished. Activities were available for people and people said they enjoyed what was provided.

Care files contained suitable information such as a care plan, and these were comprehensive and were regularly reviewed. Suitable systems were in place for ensuring people’s capacity to consent to care and treatment was assessed in line with legislation and guidance, for example using the Mental Capacity Act (2005).

People said they enjoyed the food. For example saying, “The food is marvellous.” There was not a formal choice of meals but people said staff would always arrange an alternative if people did not like what was on offer for the main meal. People had a choice of eating their meals in the lounge or their bedrooms. People said they were regularly offered a hot or cold drink throughout the day.

Nobody who we met raised any concerns about their care, and people we spoke with said there was nothing to complain about. Everyone we spoke with said if they did have concerns, they would feel confident discussing these with staff or with management. People said they were sure that staff and management would resolve any concerns or complaints appropriately.

People felt the home was well managed. For example we were told “The manager is wonderful,” and a relative told us the manager and staff had been, “Brilliant support for mum and me.”