We inspected the service on 4 and 5 December 2018. The inspection was unannounced.

Tralee Rest Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Tralee Rest Home is registered to provide accommodation and personal care for 36 older people and people who live with dementia. There were 23 people living in the service at the time of our inspection. The service is a large detached and extended house situated in a residential area just outside Whitstable.

Our last full inspection of this service took place in October 2017. Following this inspection, the key areas of Effective and Caring were rated as Good, while the areas of Safe, Responsive and Well Led were rated as Requires Improvement, together with the overall rating of the service. This was because more action needed to be taken about people who experienced falls; including more detailed audit processes. Care plans about epilepsy had been produced but needed more detail to make them truly effective. Other care plans were written in a person-centred way but had not always been updated when people’s needs changed. Medicines were generally managed safely but administration practices needed to be more consistent and recording of refused doses improved. Not all concerns raised by complainants had been logged and responded to before they became formal complaints. Audits of care plan reviews had failed to identify that details were incomplete, not always accurate or up to date. In addition, they did not consider impact on individuals in terms of reducing risk and ensuring all had been done provide support for people.

We told the registered provider to send us each month an update about the running of the service, what improvements they had made and intended to make to address our concerns and bring about improvement. The registered provider complied with this requirement.

At this inspection some improvement had been made. Incidents and accidents were all reviewed and the results used to inform any changes needed to reduce the risk of recurrence. Falls were well managed, associated risk assessments were updated and people had received support needed to reduce the risk of repeated falls. Care planning had improved and were mostly reflective of people’s current needs, however reviews of care plans had missed the opportunity to check for completeness and develop best practice procedures. Medicines were generally managed safely, although a piece of equipment used to test blood sugar levels had not been periodically calibrated and the service did not hold a stock of test fluid to allow this to be done. Complaints had been logged and responded to in line with the policy in place. Auditing and oversight had improved; however they had not been used to their expected potential as tools to assess the quality and safety of the service provided or develop best practice and continuous improvement.

As the result of this inspection, the service was rated as Requires Improvement. This is the second consecutive time Tralee Rest Home has been rated as Requires Improvement.

People were protected from harm by staff who were trained to recognise signs of abuse. However, recruitment processes did not ensure risk assessments were completed before the employment of staff for whom cautions, or convictions were recorded. Additionally, a policy was not in place to support such a process.

There were enough staff to meet people’s day to day care needs. However, people’s preferences about when they went to bed were not fully considered in the deployment of staff and may impact on or influence people’s choices.

Pre-assessments for people moving to the service were comprehensive. Staff were able to tell us confidently about the care and support people needed for specific conditions

This inspection took place on 24 and 25 October 2017 and was unannounced.

Tralee Rest Home is registered to provide personal care and accommodation for up to 36 people. There were 14 people using the service during our inspection who were living with a range of care needs. These included diabetes, epilepsy and impaired mobility; and people were living with different stages of dementia.

Tralee Rest Home is a large detached and extended house situated in a residential area just outside Whitstable. The service had a large communal lounge available with comfortable seating and a TV for people and a separate, quieter lounge. There was a small dining room in which people could take their meals.

A registered manager was in post. 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.

Tralee Rest Home was last inspected in June 2017 when it was rated as Inadequate for safety, and leadership. It was rated as Requires Improvement for being effective, caring and responsive. At previous inspections the service had also been rated as Inadequate overall and was placed into Special Measures. The provider sent us regular updates about improvements they were making.

At this inspection we found a much improved picture in most areas, but some further work was still needed around risk assessment, auditing and complaints.

Most risks to people had been properly assessed and actions were taken to minimise the likelihood of them happening. However, more action needed to be taken about people who experienced falls; including more detailed audit processes. Care plans about epilepsy had been produced but needed more detail to make them truly effective. Other care plans were written in a person-centred way but had not always been updated when people’s needs changed.

Medicines were generally managed safely but administration practices needed to be more consistent and recording of refused doses improved.

Not all concerns raised by complainants had been logged and responded to before they became formal complaints.

People were safeguarded from abuse and improper treatment and accidents and incidents were thoroughly documented. Referrals to the local safeguarding authority had been made appropriately.

There were enough skilled and competent staff on duty and people had their needs met promptly. Staff received appropriate induction and training to ensure they had the skills and knowledge to support people. Staff had opportunities to discuss their work performance, training and development. Recruitment processes ensured that only suitable staff were employed to work with people.

People were supported to eat and drink when needed and they enjoyed the variety of food provided. Weights were monitored and dietetic advice sought where people had lost weight. People’s health care needs were met by the staff and through input from a variety of clinicians and professionals.

The service was meeting the requirement of the Deprivation of Liberty safeguards and Mental Capacity Act 2005. People are 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’s dignity was respected by staff and staff delivered support with consideration and kindness. They encouraged people to be independent when they were able and people and families were involved with care decisions. End of life care plans had been improved.

There was a wide range of activity available to people; who enjoyed meaningful entertainment and individual sessions.

Policies and procedures were available to offer guidance to staff. People, relatives and staff were positive about the leadership at the service and said things had improved. Staff

This inspection took place on 26 June 2017 and was unannounced.

Tralee Rest Home is registered to provide personal care and accommodation for up to 36 people. There were 17 people using the service during our inspection who were living with a range of care needs. These included diabetes and mobility support; and people were living with different stages of dementia.

Tralee Rest Home is a large detached and extended house situated in a residential area just outside Whitstable. The service had a large communal lounge available with comfortable seating and a TV for people and a separate, quieter lounge. There was a small dining room in which people could take their meals.

A registered manager was in post, and had registered since our last inspection. 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 last inspected Tralee Rest Home in January 2017. We found significant shortfalls and the service was rated Inadequate and placed into special measures. The provider had failed to provide sufficient numbers of staff to meet peoples assessed needs. The provider had failed to assess, prevent and the control the spread of infections. The provider had not ensured the safe management and administration of medicines. The provider had not ensured that care and treatment was being provided in a safe way. The provider had failed to ensure that people received adequate diet and fluids to maintain their health and well-being. The provider had failed to ensure staff had the necessary skills and experience to enable them to carry out their duties. The provider had failed to ensure staff consistently treated people with dignity and respect. The provider had failed to take people's preferences into consideration when planning care and treatment. The provider had failed to establish and operate an effective process for managing complaints. The provider had not ensured that the systems and processes that were in operation to assess, monitor and improve the quality and safety of the service. The provider had failed to maintain accurate and complete records in respect of each person.

We took enforcement action and required the provider to make improvements. This service was placed in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. The provider sent us regular information and records about actions taken to make improvements following our inspection. At this inspection we found that although improvements had been made in some areas, other significant problems had emerged and some new breaches were identified.

Risks relating to people’s care and support were not always assessed and mitigated. People had experienced choking episodes, fallen or displayed behaviour that could be challenging and appropriate action had not been taken to protect them from risk of harm. A wardrobe had fallen and trapped a person in their bedroom and no action had been taken to prevent this from happening again. The registered manager had not consulted with the local safeguarding team about this and staff did not always document incidents when they occurred, meaning we could not be sure other incidents, leaving people at risk, would be dealt with appropriately.

People did not always receive the support they needed to eat and drink effectively. Staff did not always follow the guidelines in place for people when they needed assistance to eat, and some people were not given the equipment they needed to eat independently. The registered manager had not made necessary referrals to healthcare professionals when people had choked or fallen. People did see doctors, dentists and opticians regularly.

Staffing level

This inspection took place on 25 and 26 January 2017 and was unannounced.

Tralee Rest Home is registered to provide personal care and accommodation for up to 36 people. There were 21people using the service during our inspection who were living with a range of complex needs with some people living with different stages of dementia.

Tralee Rest Home is a large detached and extended house situated in a residential area just outside Whitstable. The service had a large communal lounge available with seating and a TV for people and a separate, quieter lounge. There was a small dining room in which people could take their meals. Accommodation for people was on two floors and a lift available for access.

A registered manager was not in post. 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. A new manager was in post who had been employed at the service for three weeks. The manager and area manager were based at the service to assess and implement improvements required.

Tralee Rest Home was last inspected in June 2016, when it was rated as Inadequate and placed in ‘Special measures’. Following that inspection we took enforcement action. Positive conditions were placed on the service on 9 September 2016. These were to not admit any person to the service without the Commission’s prior written agreement. They are required to send monthly audits of care plans and risk assessments, mattresses and air pump settings. The Commission received these audits as requested along with an action plan of how they would make improvements to the service. This inspection was to see if the improvements had effected the change required to meet the regulations.

At this inspection in January 2017 we found continued breaches of the Regulations and the overall rating of the service remains ‘Inadequate’. The service therefore remains in ‘Special measures’. Services that remain in special measures will continue to be kept under review whilst we consider what action we take under our enforcement procedures. The expectation was that the provider found to have been providing inadequate care should have made significant improvements between now and the last inspection in June 2016. For adult social care services the maximum time for being in special measures would usually be no more than 12 months.

People were not protected against identified risks to their health, safety or well-being. This included risks associated with the control of infection. The cleaning regime throughout the home was ineffective in ensuring all areas of the service and equipment was clean and controlled the risk and spread of infection.

The management of medicines was unsafe and people were at risk of not receiving medicines prescribed to them by their GP. The storage, administration and recording of medicines did not follow recommended guidance to keep people safe from harm.

Staffing levels remained insufficient to support the needs of the people at the service. Some essential training had been delayed and staff did not all have the necessary skills to enable them to carry out their duties and provide effective care and treatment for people.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These safeguards protect the rights of people using services by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect the person from harm. Staff understood how to follow the principles of the MCA had been appropriately sought. Staff had received safeguarding vulnerable adults training. However, safeguarding concerns had not always been raised with the local authority.

Staff were focused on

This inspection took place on 22 and 23 June 2016 and was unannounced.

Tralee Rest Home is registered to provide personal care and accommodation for up to 36 people. There were 25 people using the service during our inspection who were living with a range of care needs. These included diabetes and mobility support; and people were living with different stages of dementia.

Tralee Rest Home is a large detached and extended house situated in a residential area just outside Whitstable. The service had a large communal lounge available with comfortable seating and a TV for people and a separate, quieter lounge. There was a small dining room in which people could take their meals.

A registered manager was in post. 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.

Tralee Rest Home was last inspected in December 2015, when it was rated as Requires Improvement overall, but safety of the service was rated as Inadequate. We found a number of breaches of Regulation at that inspection and issued requirement actions and warning notices. The provider sent us an action plan to tell us how they would address the breaches. This stated that all remedial actions would be completed by 30 March 2016.

At this inspection we found that although improvements had been made in some areas, other significant problems had emerged.

People had not consistently been protected against identified risks to their health, safety or well-being. This included risks associated with the control of infection, skin integrity and medicines. There was no robust system in place for raising safeguarding alerts with the local authority. We witnessed a safeguarding incident and made a referral to the local authority following our inspection.

Staffing levels had been increased following our last inspection but the competency of those on duty was not universally sufficient. Training and supervision had not been wholly effective in some areas and recruitment checks were incomplete.

Maintenance of the premises had improved but identified problems had not always been remedied promptly. Fire and equipment safety checks had been regularly carried out and there was a reciprocal arrangement with another home in the event of an emergency evacuation. The premises had clear signage to help people living with dementia to orientate themselves.

The principles of the Mental Capacity Act had not been followed with regard to obtaining consent, but Deprivation of Liberty Safeguards (DoLS) had been appropriately sought.

People’s healthcare had not been properly considered when they had diabetes. Other people saw opticians, chiropodists and dentists on a regular basis. People were offered a choice of meals and appeared to enjoy them but food supplements had not been managed correctly.

Care plans were person-centred and detailed but they were not always an accurate reflection of the care people received. Information about people’s life histories had been complied to give staff a sense of people’s personalities and achievements. People engaged in a variety of group and individual activities.

Complaints had been managed effectively and people had keyworkers to support them if they wished to raise concerns.

The service was not well-led and quality assurance processes had failed to identify a range of issues highlighted by the inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements

The inspection visit was carried out on 29 January 2015 and was unannounced. The previous inspection was carried out on 13 & 17 December 2013, and no breaches were found with the regulations.

Tralee Rest Home provides accommodation and personal care for up to 36 older people living with dementia. The service was providing accommodation for up to 34 older people at the time of the inspection, as two of the bedrooms could be shared by two people, but were being used as single rooms.

Accommodation is provided on two floors, with access to the first floor via a passenger lift. The premises include an original old building, with a large purpose-built extension. The service is situated in a residential area of Whitstable, near to the town and the beach.

The service is run by a registered manager, who was present on the day of the inspection visit. 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 and associated Regulations about how the service is run.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and DoLS. No-one living at the home was currently subject to a DoLS authorisation, but the registered manager had discussed when to make applications with the lead person for the local authority DoLS team, and was following their advice.

The service had suitable processes in place to protect people from different types of abuse. All of the staff had been trained in safeguarding people and in the service’s whistleblowing policy. (Whistleblowing enables staff to raise matters of concern about other staff in an unbiased way, and without fear of discrimination). Staff were confident that they could raise any matters of concern with the registered manager or with the local authority safeguarding team.

The service did not meet the requirements for maintaining effective infection control procedures. There was a lack of liquid soap and paper towels available in communal toilets and bathrooms; and a lack of foot operated pedal bins for used paper towels. The floor and walls in the laundry area included exposed brickwork and floor tiling, which did not provide a continuous surface which could be easily cleaned. There were no separate hand washing facilities in the laundry. This presented an infection control hazard. The registered manager was not familiar with the ‘Code of Practice for health and adult social care on the prevention and control of infections and related guidance’ and did not have a copy of this document. (The Code of Practice sets out the requirements for regulated services to meet the regulation for cleanliness and infection control).

The service had procedures in place to maintain the environment and equipment in good working order. Regular checks were carried out for equipment such as mobile hoists, bath hoists, fire alarm systems, fire doors, nurse call system and emergency lighting. However, there was a lack of arrangements and equipment to move people with restricted mobility out of first floor rooms in the event of an emergency.

The registered manager had systems in place to record accidents and incidents, and to monitor these to see if there were any patterns of occurrence, such as the same time of day, or the same staff on duty. Records showed that these were analysed to assess if any action could be taken to avoid further accidents, and identified action was taken in response.

Care staff were evident throughout the service during our inspection visit, offering support to people who were walking about or sitting in their rooms or communal areas. Relatives said that the registered manager and staff were always easily available. The registered manager was recruiting for two posts in care and for an activities co-ordinator. The service employed staff from an agency to ensure sufficient numbers of care staff were on duty, if existing staff were unable to carry out additional shifts. The registered manager always asked existing staff first, as this provided continuity of care for people living with dementia.

The service had reliable staff recruitment procedures in place. Applicants were assessed as suitable for their job roles, and new staff were provided with a detailed induction programme, which included training in essential subjects. Refresher training was provided at regular intervals.

Medicines management was overseen by the registered manager, who carried out arrangements for repeat prescriptions and receipt of medicines into the home. Only senior staff who had completed training and been assessed for their competency were permitted to administer medicines.

Staff were supported through daily handovers between shifts, staff meetings, individual supervision sessions and yearly appraisals. They were able to develop their knowledge and skills through further training courses, and formal qualifications. Staff demonstrated their understanding of the Mental Capacity Act 2005 and how to apply this, by encouraging people to make individual choices about their daily lifestyles, and respecting their decisions. This included choices such as where they wanted to sit, what they wanted to wear, and what they wanted to eat.

People said they enjoyed the food. The menus showed there was a wide variety, providing a nutritional diet. Food was attractively presented. People were encouraged to eat together at dining tables, so as to provide social inclusion and the enjoyment of interacting with other people at meal times.

Staff had a friendly and caring approach to people, and it was pleasant to hear their kind words of encouragement, and to view their patience in caring for people. They did not rush people for responses, but listened quietly and gave people time to respond to questions.

People and their relatives were involved in their care planning, depending on the wish of the person receiving care, and their ability to understand the information. Care plans showed that their health needs were assessed, and were monitored accordingly. A GP visited the service each week, or more frequently if the need arose.

People did not have access to a sufficient range of activities at the time of our inspection. This was partly due to on-going recruitment for an activities co-ordinator. There was a range of games and activities available in a small lounge at the front of the premises, but there was little evidence that people were actively offered the opportunity to take part in these during the day. There was a lack of sensory items for people living with dementia to enjoy; and access to the garden was limited to people who had sufficient mobility to manage steps down to the lawn. This did not ensure the welfare of people living in the service.

People and visitors were supported in voicing their feelings, their concerns, and complaints. The complaints procedure included information and contact details for the registered manager, the regional manager, and other organisations, including CQC. A monthly complaints log was sent to the head office so that the company could monitor complaints and check they were being followed through appropriately.

The registered manager had a daily visible presence in the home and led the staff in caring for people. Senior care staff were on duty for each shift to assist the registered manager with oversight of the staff, and support them in providing effective care. Staff said that the registered manager was very approachable and listened to their views.

The registered manager carried out a range of monthly audits to assess and monitor the progress of the home. These identified shortfalls in the service and action was taken in accordance with the findings. However, the infection control auditing process was incomplete, and had not identified and addressed the issues which compromised effective infection control in different areas of the service. Health and safety audits had failed to show that there was a lack of suitable equipment in an emergency to assist people with restricted mobility to move from rooms on the first floor.

People and their relatives knew that the registered manager had an open door policy, and that they could talk with her whenever they wished to. Their feedback was obtained through daily conversations, phone calls and e-mails, and through the use of yearly surveys carried out by the provider. Yearly questionnaires were also sent out to visiting health professionals; and questionnaires were given out to people living at the service every three months. This provided them with a regular opportunity to raise any concerns about the service. People’s comments were used to bring about change and on-going improvements to the service.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not all able to tell us their experiences

We found that there were care plans, health files and person centred plans in place for all people that used the service and that these were regularly reviewed and changes made as necessary.

Records showed that staff had been properly recruited, trained and supervised and that the service had systems in place to safeguard people. We found that the service monitored quality of care regularly and acted on any issues that had arisen.

We found that there was a system for the safe storage and dispensing of medication. We found the premises to be safe and suitable.

We carried out this visit to review improvements made in regards to the environment since our last visit in June 2011.

We chatted briefly with a few people living in the home, and saw that many of them were smiling, and looked relaxed. Some of them greeted us, but we did not have any meaningful conversations on account of people's dementia.

We met most of the people living in the home, and talked with seven of them. Their conversation was mostly muddled, but we saw that they were smiling, generally relaxed, and appeared to be comfortable and happy living in the home. One person said that “everyone was very nice”.

We talked with two relatives, and they said that they were “delighted with the standards of care here” and it was “the most caring home they had been in”.

This inspection took place on 3 and 4 December 2015 and was unannounced. Tralee Rest Home is a care home which provides care and support for up to 36 older people living with dementia. There were 31 people at the service at the time of our inspection. People were living with a range of care and health needs, including diabetes and epilepsy. Many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more physically independent and needed less support from staff.

The service had a registered manager in post at the time of our visit. 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.

Tralee Rest Home was last inspected on 29 January 2015.They were rated as Requires Improvement at that inspection. We issued Requirement Notices and asked the provider to submit an action plan to us to show how and when they intended to address them. We found that the provider had met some, but not all of the Requirement Notices during this inspection. In addition we identified further areas where the provider was not meeting Regulations in the delivery of care to people living at Tralee Rest Home.

Risks to people’s safety and welfare had not always been appropriately addressed. Medicines and creams had not been managed consistently, and actions to minimise some other risks such as to people’s skin or their nutrition, had not been followed through. The risk of the spread of infection remained, because the service had failed to meet adequate standards of cleanliness and hygiene. There was not a robust system for raising safeguarding concerns with the local authority, because the registered manager did not fully understand the types of incident or event that should be reported.

There were not enough staff to meet people’s needs, because some people’s dementia meant that they showed behaviours that required greater levels of staff input to manage them. Staff and manager training had not always been effective and there were gaps in their knowledge in some areas. Staff had regular supervisions and appraisals and new staff completed a detailed induction programme.

The principles of the Mental Capacity Act 2005 (MCA) had not been properly followed in regard to consent, but applications to authorise deprivations of people’s liberty (DoLS) had been made by the registered manager.

Staff were caring and considerate and treated people with dignity. There were now suitable activities available for people to enjoy. An activities coordinator had been employed and during this inspection people made Christmas decorations and played games together.

Relatives knew how to complain and complaints had been handled appropriately by the registered manager. There were a number of methods by which relatives and visitors could provide feedback about the service. Staff surveys were conducted and regular staff meetings were held, to provide staff with the opportunity to raise any concerns.

Auditing remained ineffective in highlighting shortfalls in the quality and safety of the service, but the provider had reviewed and updated their policies since our last inspection.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.