Trecarrel is a care home which offers care and support for up to 44 predominately older people. At the time of the inspection 27 people were living at the service. Some of these people were living with dementia.

The service was last inspected in July 2018 and was rated as Inadequate. In July 2018 we received serious concerns from health and social care professionals about the care that people received. The concerns were in relation to, personal care needs not being met, care plans and risk assessments were not in place for some people, medication, nutrition, staffing levels, staff culture, staff training, moving and handling concerns, infection control practices, lack of confidence in record keeping, and concerns regarding leadership of the service. Due to the service being rated inadequate it was placed in ‘special measures.’ Due to this, we imposed conditions on the providers registration to provide us with a monthly audit to provide assurance in how the service would address its shortcomings.

This comprehensive inspection took place on 3 October 2018 and was unannounced. Two inspectors and a Specialist Advisor with an Expert by Experience visited the service. We had received form the provider regular audits which outlined what action they had taken since the last inspection in July 2018.

The findings of this inspection demonstrated that the provider and management team had worked in an open and transparent manner. The provider had complied with four breaches of regulation. This included in the areas of ensuring care plans and risk assessments were in place, nutritional needs had been met, mental capacity procedures were being followed, staff were receiving the appropriate induction, supervision and training, infection control processes were more robust, and repairs had been undertaken to the premises to ensure people’s safety.

The provider acknowledged that further work needed to be undertaken to ensure that new systems and process were imbedded. For example, at this inspection we still found that some records were not consistently being completed, such as monitoring records. Some records would benefit from expansion to ensure they captured the persons physical, emotional and social needs, for example care plans and food and fluid charts. We also did not see any activities provided during the inspection, and feedback from relatives and people was that they wished there was more to do to occupy their time. There was no evidence people’s preferences were taken into account when organising their routines. We have identified a repeated breach of regulation in this respect.

The provider had commissioned an independent consultancy company to provide an overview of the auditing systems in all of their services. They have commissioned this work as an ongoing project as the provider wanted to ensure that effective auditing systems were in place to be proactive in identifying any future short comings in the service at a much earlier stage.

During the inspection we spoke with staff, people and relatives. All spoke of the need for change at Trecarrel Care Home and were positive in how the senior managers had approached this, and all felt that as a result the care of people had “improved significantly.” Staff said they felt more supported. All agreed that this remains “early days” and that the changes needed to be imbedded in all aspects of the service.

In discussion with health and social care professionals all spoke of the improvement to peoples care at the service. They also commented about the improvements in the staff team, “The atmosphere is heads up not eyes down now. The senior carers are working much better now too” and “I have a lot of faith in the staff that they want to make a difference.”

This inspection identified that there was an issue regarding the staff deployment around the service. This meant that there were substantial periods of time when people were isolated in communal areas and not supported by staf

Trecarrel is a care home which offers care and support for up to 44 predominately older people. At the time of the inspection 39 people were living at the service. Some of these people were living with dementia.

The service was last inspected in November 2016 and was rated as Good. In July 2018 we received serious concerns from health and social care professionals about the care that people received. The concerns were in relation to, personal care needs not being met, care plans and risk assessments were not in place for some people, medication, nutrition, staffing levels, staff culture, staff training, moving and handling concerns, infection control practices, lack of confidence in record keeping, and concerns regarding leadership of the service. Due to these concerns we brought our inspection forward. The inspection found significant concerns at the service.

This comprehensive inspection took place on 17 and 18 July 2018 and was unannounced. Two inspectors and a Specialist Advisor visited the service on the 17 July 2018. An inspector visited the service on the 18 July and met with the senior management team to discuss our findings of the inspection.

The service is required to have a registered manager. Following the safeguarding concerns being raised the manager was no longer employed by the organisation. On being informed of the concerns, the provider promptly deployed their operational management team to address the concerns and support the service. On the 9 July 2018 an interim manager was appointed at the service. Following the inspection, the operational manager clinical lead was appointed to manage the service as they had more experience to address the level of concerns at the service.

Some care staff had not received any training in safeguarding and had limited or no knowledge about the safeguarding process and how to recognise potential signs of abuse or mistreatment.

Some people’s care plans, were not effectively updated to ensure they were reflective of people's current care needs. Following commissioner’s reviews of people’s care needs, it was evident that some people’s health needs had changed. This meant that people’s health needs had not been reviewed appropriately by the service to ensure they could continue to meet the person’s current health and care needs.

People’s risks were not safely managed at the service. For example, a number of people were at risk of falls or risks in relation to their dietary needs. There was no relevant risk assessment in place or documentary evidence to support how the risks could be minimised to keep the person safe. Consultation with those involved with the person was not evident. Therefore, we were not assured that risks had been properly considered and addressed.

The interim manager had developed a new handover system as they were aware that, due to the lack of accurate care plans, staff had limited guidance, information or direction in how to meet people’s needs. The interim manager was aware that this needed to be developed further.

The Local Authority systemic safeguarding meeting raised concerns about the safe administration of medicines at the service. Due to this a community pharmacist visited the service on the 16 July 2018. They undertook an inspection and identified where further action was needed to ensure the safe management of medicines. We reviewed their notes and inspected medicines and found the same issues as the community pharmacist.

The senior management team were unable to identify which person had been subject to a mental capacity assessment. They were also unable to evidence where any applications had been submitted to the Deprivation of Liberties Safeguard (DoLS) team. The clinical lead was able to inform us that they had identified two people who had conditions attached to their DoLS authorisation and these conditions were not being met. This meant it was not possible to understand what decisions the service had taken on behalf of others

Trecarrel Care Home provides care for primarily older people, some of whom have a form of dementia. The home can accommodate up to a maximum of 44 people. On the day of the inspection 44 people were living at the service. At the time of our inspection some people had physical health needs and some mental frailty due to a diagnosis of dementia.

This unannounced comprehensive inspection took place on 23 November 2016. The last inspection took place on 10 May 2016. There were breaches of the legal requirements at the last inspection. We were concerned that a new care plan format had not been fully implemented and some care plans did not contain sufficient individualised information to effectively guide and direct staff to meet people’s needs. There were gaps in staff training provision which meant staff skills and knowledge may not have been up to date. Recruitment and induction processes were not always robust. One person was found working at the service without Disclosure and Barring Service checks and sufficient references having been sought. The service did not have a registered manager in post at the time of the last inspection and there were not effective processes in place to assess and monitor the quality of the service provided.

Following the inspection in May 2016 the provider sent the Care Quality Commission an action plan outlining how they would address the identified breaches.

We were concerned that some people living at the service had bedroom doors which were locked and did not have door handles that enabled people to easily open their own door. People did not hold the keys to their locked bedrooms but needed to ask staff to open their doors when required. Upstairs there was a coded lock on the landing leading to bedrooms that were all locked with a key. Staff were not always present upstairs where people were living with dementia and were independently mobile. No having easy access to their bedrooms did not support people’s choice and independence. One person had fallen upstairs and was found on the floor by staff. The registered manager assured us they were confident that the people living upstairs were appropriately placed as they preferred the quieter environment. However, they agreed they would review the locked bedroom doors with a view to making them more accessible to people.

The service had a registered manager in post. 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.

We walked around the service which was comfortable and personalised to reflect people’s individual tastes. People were treated with kindness, compassion and respect. Staff took time to chat with people every time they passed.

We looked at how medicines were managed and administered. We found it was possible to establish if people had received their medicine as prescribed. Regular medicines audits were consistently identifying if errors occurred.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met.

Staff were supported by a system of induction training, supervision and appraisals. Staff knew how to recognise and report the signs of abuse. Most staff received training relevant for their role and there were opportunities for on-going training support and development. More specialised training specific to the needs of people using the service was being provided for most staff. For example, dementia care training. Staff meetings were held for all staff teams. These allowed staff to air any concerns or suggestions they had regarding the running of the service and improved communication between management and staff teams.

Meals were appetising and people were offered a choice in line with thei

Trecarrel Care Home provides care for primarily older people, some of whom have a form of dementia. The home can accommodate up to a maximum of 44 people. On the day of the inspection 39 people were living at the service. Some of the people at the time of our inspection had physical health needs and some mental frailty due to a diagnosis of dementia.

Two inspectors carried out this unannounced focused inspection on the 10 May 2016. At this visit we checked what action the provider had taken in relation to concerns raised during our last inspection in October 2015. At that time we found breaches of legal requirements in respect of the following areas: a lack of infection control measures were in place: a lack of training and supervision for staff: care plans were not up to date and auditing systems were ineffective.

This report only covers our findings in relation to the ‘Safe’, ‘Effective’, ‘Responsive” and Well Led’ questions covered in this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Trecarrel on our website at www.cqc.org.uk

The service is required to have a registered manager and at the time of our inspection there was no registered manager in post. A registered manager is a person who has registered with the CQC 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 provider had appointed a new manager January 2016. The manager had not yet submitted their registered manager application to the Commission but reassured us this was in process.

We had received anonymous concerns about how people were cared for at Trecarrel Care Home. At this visit we looked at the anonymous concerns raised. They related to a lack of individualised detail in people’s care plans to ensure their needs were met, concerns in relation to medicines, staffing levels, staff support and the changes that had occurred at the service since the appointment of the new manager.

We found new processes and systems had been introduced. For example, infection control processes were now in place and being followed. Staffing levels had been reviewed which had led to the introduction of an additional member of staff on the newly introduced ‘twilight shift’. Staff supervision was now in place.

We noted that further work was needed in certain areas of the service. For example, a new care plan format had been introduced and a review of people’s care needs was commencing. The care plan formats needed to be developed further to include areas of care around medicines and mental capacity. Currently staff had reviewed four people’s plan of care and aimed to have reviewed every person living at Trecarrel within a three month timescale. We also noted that a training matrix had been developed. From this it was evident that there were gaps in staff training which need to be addressed so that staff skills remained up to date.

We had received anonymous concerns about the new systems that the manager had introduced. Staff t stated that initially it was difficult to acknowledge or accept that changes were needed. They were now able to see the positive impact of some of the changes that have been implemented. Staff sickness had lowered and staff said they felt morale had improved. Some comments from staff included; “We’ve needed this for a while”, “All the changes are good. Some staff haven’t been ok with the changes but we need a leader” and “It’s going in the right direction.”

It was acknowledged from the manager and from all staff at the service that a lot of changes had been needed and some of these changes were difficult to acknowledge or accept. However work in continuing to improve communication within the Trecarrel staff team is still needed. This would provide staff with sufficient information to

Trecarrel care home provides care for primarily older people, some of whom have a form of dementia. The home can accommodate up to a maximum of 44 people. On the day of the inspection 43 people were living at the service. Some of the people at the time of our inspection had physical health needs and some mental frailty due to a diagnosis of dementia.

Two inspectors carried out this unannounced inspection on the 2 October 2015.

The service is required to have a registered manager and at the time of our inspection there was no registered manager in post. A registered manager is a person who has registered with the CQC 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 provider had notified us of this absence and had kept us informed of the recruitment to this post. The management team structure had been reviewed since the registered manager had resigned. An increase to three deputy managers at the service had recently occurred, along with the appointment of the operations manager.

We had received anonymous concerns about how people were cared for at Trecarrel Care Home. At this visit we looked at the anonymous concerns raised. They related to a lack of individualised detail in people’s care plans to ensure their needs were met, concerns about staffing levels and support and concerns regarding how people were supported to mobilise around the service safely.

From this inspection we identified a number of concerning issues. The operations manager and deputy managers acknowledged that the lack of an effective management presence had led to certain areas of the service not meeting acceptable standards. For example there were concerns around risk assessments, infection control and moving and handling practices. In respect of staff, there were concerns around their induction to their role and ongoing support and training which meant that staff were not enabled to meet people’s needs. In respect of care planning we noted that people’s care plans did not provide staff with sufficient accurate information to enable them to meet people’s current care needs. Vital information for staff to follow to ensure people’s safety and welfare was not always recorded in care records. This inspection demonstrated, that whilst peoples care needs were being met, there were issues of the systems and processes within the service. The quality assurance system was not robust as it was not up to date and failed to identify areas of significant concern. The deputy manager and operations managers acknowledged that standards had deteriorated and that work to improve standards needed to occur.

People told us their experience of the service. Some comments included “it’s wonderful here,” “staff are lovely” “the food is wonderful” and “This is the best place for me.” Relatives also shared the view that their family member received appropriate care by caring staff. Health professionals told us “Staff are good, they are kind and caring and have time for people.”

People felt safe living in the home and relatives told us they thought people were safe. Staff knew how to recognise and report the signs of abuse. They knew the correct procedures to follow if they thought someone was being abused. We saw throughout our visit people approaching staff freely without hesitation and that positive relationships between people and staff had been developed.

People were complimentary about the quality and quantity of the food provided. People were complimentary about the staff telling us they are “Marvellous” “caring” and “lovely”. They told us they were completely satisfied with the care provided and the manner in which it was given. Relatives were complimentary about the care provided.

People chose how to spend their day and some activities were provided. Activities were provided by the service individually and in a group format, such as arts and crafts and through outside entertainers coming into the service. Relatives told us they were always made welcome and were able to visit at any time.

The operations and deputy managers had an understanding of the Mental Capacity Act 2005 (MCA) and how to make sure people who did not have the mental capacity to make decisions for themselves had their legal rights protected. Where people did not have the capacity to make certain decisions the home involved family and relevant professionals to ensure decisions were made in the person’s best interests.

We saw staff providing care to people in a calm and sensitive manner and at the person’s pace. When staff talked with us about individuals in the service they spoke about them in a caring and compassionate manner. Staff demonstrated a good knowledge of the people they supported. Peoples' privacy, dignity and independence were respected by staff. We saw many examples of kindness, patience and empathy from staff to people who lived at the service.

We saw the service’s complaints procedure which provided people with information on how to make a complaint. People told us they had no concerns at the time of the inspection and if they had any issues they felt able to address them with the management team.

We found four Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the end of the full version of the report.

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We gathered information from people who used the service by talking with them.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

At the time of the inspection people told us they felt safe. Systems were in place to help the manager and staff team learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. Staff showed a good understanding of the care needs of the people they supported.

Trecarrel alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service.

Trecarrel had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS), and further staff training was planned. This helped to ensure that people’s needs were met.

Is the service effective?

At the time of the inspection people were not always involved in writing or reviewing their plans of care. During our inspection it was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people’s needs.

Specialist dietary needs had been identified where required. Care plans were up-to-date.

We saw that there was good liaison and communication with other professionals and agencies to ensure people’s care needs were met.

Is the service caring?

We spoke with people being supported by the service. We asked them for their opinions about the staff that supported them. At the time of the inspection feedback from people was positive, for example, “I find the staff to be friendly, helpful and kind”.

Trecarrel had regular support from the GPs from the local GP practices and other visiting health professionals. This ensured people received appropriate care in a timely way.

Is the service responsive?

At the time of the inspection many people who lived at Trecarrel had complex health needs and were either not able, or chose not to join in group activities. There was evidence to show that people were routinely offered one-to-one time or group activities.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

At the time of the inspection Trecarrel did not have a registered manager, but the manager confirmed they were in the process of submitting an application to be the registered manager.

We saw minutes of regular meetings held with the staff. This showed the management consulted with staff regularly to gain their views and experiences and improve support for people who lived at the service.

The service had a quality assurance system, and staff were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

As part of our inspection, we met and spoke with the new manager who had been appointed since our previous inspection, senior care staff, care staff and housekeeping staff.

We spoke and met with people who lived at Trecarrel. People we spoke with told us, “There [staff] so patient and kind”, “kind and helpful” and “very good, very well looked after”. One relative told us they thought the home was “excellent”.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

As part of our inspection, we met and spoke with the registered manager, the deputy manager, and care staff at Trecarrel Care Home.

Some people who used the service where able to tell us their views about the care and support they received. However, the people who lived at Trecarrel Care Home predominately had dementia type illnesses and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences of people, we used our Short Observational Framework for Inspection tool (SOFI). The SOFI tool allowed us to record how people spent their time, the type of support they received and whether they had a positive experience.

People experienced care, treatment and support that met their needs and protected their rights.

People were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

There were enough qualified, skilled and experienced staff to meet people’s needs.

There was an effective complaints system available.

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 other

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

One person we spoke with who used the service told us “the staff are so lovely, they look after me brilliantly and nothing is too much trouble for them”. Another person told us they were satisfied with the care they received and added “I have no complaints I am looked after very well”.

The home was clean, tidy and free from odours. Refurbishment had taken place with new carpets in communal areas and some bedrooms. We also noted some new furniture was in place.

Staff were seen to be busy during the whole inspection due to the care needs of people who lived at Trecarrel. Despite this a relaxed and calm atmosphere remained and we observed that the staff treated people with respect and showed empathy and compassion for the people they cared for.

We saw the staff offered people choices of how they spent their day. For example, what time they got out of bed, where they sat in the home, activities they took part in and what they wanted to eat. Staff were patient and demonstrated they had a knowledge of people's care needs and their preferences and choices.

People were offered a wholesome and nutritious diet from the planned menu which afforded them a choice at each meal. We were told the food was good.

We talked with people who use the service and live at Trecarrel. We were not able to have full conversations with everybody due to their medical conditions.

One person told us that the staff were kind and helpful to them. We asked people if they could make choices about how they spent their day. One person said that they got up and went to bed when they wanted to. Another person said that they always get up early but were not sure, when we asked them, if this was their choice.

We observed staff interacting with people who use the service during the day. Staff were respectful and and we saw that they offered people choices, for example of where they wished to sit and who they sat with.

We saw that staff respect the privacy and dignity of people who use the service.

We spoke with a visitor to the home. This person had recently had a relative who lived in the home. They told us that the staff looked after their relative very well and were always respectful and kind to both their relative and to the family when visiting the home. The visitor said that the home is always clean, warm and welcoming to visitors and added that they thought the home was homely and comfortable.

People we talked with who use the service told us that they like their rooms. One person was complimentary about the domestic staff, saying that they worked very hard and the home was always very clean and tidy.

We talked to people who use the service and who were able and willing to speak with us.

We were told that people like the staff and that they are kind and helpful. Some people confirmed that they had the opportunity to make choices about their day and these choices were respected. Other conversations that we had with people did not clearly identify whether the person themselves made choices or the staff did.

People told us that there were group activities taking place in the communal areas in the home. People were not able to tell us what activities were available to them if they preferred to stay in their room.

People who live at Trecarrel told us that they think their rooms are nice, big enough and one person said that they had brought things from home.

While one person told us that if they rang their bell, the staff responded quickly, not everybody had access to a call bell in their room.

Two people who use the service told us that they did not have access to hot water in their bedrooms.