About the service:

Trefula is a care home that provides personal and nursing care for up to 44 people, all who are living with dementia, and / or have other mental health issues. At the time of the inspection 41 people lived at the service. All of the people lived there permanently. The service primarily caters for people aged 65 and over, although at the time of the inspection some younger people were accommodated. The service was divided into two restricted units; ‘St Mawes’ / ‘Restormel’, and ‘Pendennis’ / ‘Carn Brea’. Pendennis / Carn Brea provided a higher emphasis on general nursing care. Both accommodated people with dementia and/or other mental health care needs.

People’s experience of using this service:

¿ Steps taken to minimise the risk of unwelcome visitors going into other people’s bedrooms were not always effective. This caused some people anxiety. Suitable steps were not taken to safeguard people.

¿ Risk assessment processes were not always safe for example, in the case of specific individual’s: regard to the use of bedrails, emergency evacuation plans in the case of a fire; pressure sore prevention.

¿The lack of suitable recruitment checks put people at risk from staff who were not fit to work with vulnerable people. Staffing levels and deployment was not always sufficient to meet people’s needs.

¿ Medicines were not always managed safely. The management of external preparations, such as creams and lotions, was not effective. The service did not have an effective audit system. People’s medicines such as skin patches were not always managed safely. The gaps between medicine rounds were often not satisfactory which could result in medicines being given too closely together.

¿ Infection control procedures were not always effective. For example, we had concerns about the storage of some infection control products, and the cleanliness of some areas within the service.

¿ Assessment processes, before people came to live at the service, were not always satisfactory, and led to the service agreeing to admit some people who were not suitable to live there.

¿ Staff induction, training, supervision and appraisal systems were not always satisfactory. This meant staff were not always equipped with the right skills, knowledge and support.

¿ People did not always receive the correct support with eating and drinking. For example, this put some people at risk of choking. Records kept were not always sufficient.

¿ Health care records were not always comprehensive and did not detail what treatment people had received, or when this was next required.

¿ People’s rights were not always maintained in line with the Mental Capacity Act 2005. For example, when conditions were applied to Deprivation of Liberty Safeguard agreements, there was not always sufficient evidence these were being met. Staff training and knowledge about the Mental Capacity Act 2005 was not always effective.

¿ People did not always have access to a call point to summon staff in emergency

¿ People did not always have regular opportunity to have a bath or a shower.

¿ Care planning and guidance for staff to provide good quality care was not always satisfactory. Care plans were not always reviewed regularly and therefore were inaccurate.

¿ There were not sufficient planned activities available to people on a regular basis.

¿ End of Life care planning was not satisfactory and did not give staff guidance about people’s wishes and needs.

¿ Management was not effective, and had not provided person centred high quality care.

¿ Governance arrangements were not satisfactory. For example, there were inadequate audit and quality assurance arrangements to assess service quality, and bring about improvements when required.

¿ People said they liked the food, were provided with a choice, and were offered regular drinks.

¿ People said they liked the staff, and staff were kind and respectful.

¿ Staff said training was good, and they had received comprehens

We inspected Trefula House on 2,3 and 8 October 2018. The inspection was unannounced. At the last inspection, in July 2016, the service was rated Requires Improvement and we issued the service with two statutory requirements about the need to take suitable action when people lacked mental capacity, and treatment of skin damage due to wounds and pressure damage. At this inspection, although we found, overall, suitable action had been taken in these areas, the service was again rated as Requires Improvement due to concerns about the management of the medicines system, concerns about care planning, and quality assurance processes.

Trefula 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. Trefula accommodates 44 people across two separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. In the other unit people may also have dementia, but there was also a greater emphasis on nursing care for people who were physically unwell.

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.

At the last inspection we had some concerns about personal care and skin care for some people. As part of this inspection we liaised with the community tissue viability team. They said staff liaised well with them and they had no concerns about pressure relief and wound care. We assessed the care of people at risk of pressure damage. We had no concerns about care delivered by staff. Overall records demonstrated suitable care and treatment for people with these needs although there was still some inconsistency how these records were kept in respect of this aspect of care.

At the last inspection we also had some concerns about whether people’s rights to consent to their care, and measures taken if people could not, were suitably managed within the boundaries of the Mental Capacity Act 2005. At this inspection we found people had a fully completed mental capacity assessment, and where necessary applications had been submitted to the local authority where the registered persons’ had assessed a person lacked capacity. However, we did have concerns there was not suitable information to readily demonstrate any conditions of any authorisations to deprive someone of their liberty were being acted upon. Also, we had concerns that nursing staff within the care home were signing treatment escalation plans, which served to say people should not be resuscitated should this be medically necessary, and the person lacked capacity. These should have been signed by external professionals. Some people had behaviour which challenged the service. As a result these people sometimes required staff to use physical behaviour techniques to prevent them from harming themselves or others. Where this was necessary guidance, about individuals needing this support, was limited. For example, there was a photocopy of what physical holds should be used but this was generic and not person centred.

People, and their representatives told us they were safe. For example, comments we received included: “There’s just a nice safe feeling about the home.” Suitable policies and procedures were in place to ensure people were protected if there were any allegations of abuse. Staff had received safeguarding training. Due to concerns about how two people were looked after we did put in two safeguarding referrals following this inspection.

The service had suitable policies and procedures about risk assessmen

We inspected Trefula House on 6 and 7 November 2017. The inspection was unannounced. At the last inspection, in July 2016, the service was rated Good. At this inspection we found the service required improvement and identified two breaches of the regulations.

Trefula 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. Trefula accommodates 44 people across two separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia.

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.

We had some concerns about personal care and skin care for some people. We concluded the registered persons should have liaised more promptly with tissue viability nurses when there were concerns about the effectiveness of pressure relief, and when people’s skin conditions failed to improve as planned.

We also had some concerns about whether people’s rights to consent to their care, and measures taken if people could not, were suitably managed within the boundaries of the Mental Capacity Act 2005. The majority of people did not have capacity. However not everybody had a fully completed mental capacity assessment. Due to some people’s behaviour, approved techniques to assist people to minimise any difficult behaviours needed to be used. However guidance, about individuals needing this support, was limited. There was no evidence that the multi-disciplinary team had made decisions, through a best interest process, about the techniques used.

People were safe. For example, one person told us: “Staff make me feel safe. They are nearby if I need them.” Suitable policies and procedures were in place to ensure people were protected if there was any allegations of abuse. Staff had received safeguarding training.

The service had suitable policies and procedures about risk assessment to monitor any risks to people (such as poor nutrition and hydration, and falls) or others (such as aggression).

Equipment (such as hoists and wheelchairs) were suitably maintained. Health and safety checks (for example checking fire precautions, and electrical checks) were routinely completed appropriately.

Staffing levels were satisfactory. Call bells were answered promptly on the day of our inspection and an external professionals commented: “The staffing levels seem appropriate and carers appear caring and supportive.” Satisfactory staff induction processes were in place. Staff were generally appropriately trained to carry out their jobs, although we did think training about pressure ulcer prevention, and wound care could be improved. Staff recruitment checks were satisfactory. The staff supervision and appraisal system needed to be improved so staff received more frequent meetings with their supervisor. However, staff told us they felt supported by management.

The medicines system was generally satisfactory, although the management of creams, eye and ear ointments needed some improvement. We have made a recommendation in relation to this.

The service was clean and hygienic. Staff received training about infection control and understood the need to wear protective clothing as necessary. There were suitable pre admission assessment procedures, to check if people’s needs could be met. Every one had a care plan and these were regularly reviewed.

People were happy with the food. People had a choice of meals. Someone told us: “The food is always hot and tasty. “Where people needed to have what

Trefula is a care home with nursing which provides accommodation for up to 37 older people. At the time of the inspection 37 people were using the service. The service was separated into two units; general nursing, and a dementia service. Some of the people who lived at the service needed care and support due to dementia, other mental health, and sensory and / or physical 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 Trefula on 25, 26 and 27 July 2016. The inspection was unannounced. The service was last inspected in July 2015 when it was found to not be meeting the requirements of the regulations. At that inspection we identified two breaches of the legal requirements. These breaches related to how medicines were managed and the delivery of training. We subsequently issued two requirements and told the provider to take action to address the two breaches of the regulations. The provider sent the Care Quality Commission an action plan following the publication of the report. We carried out this inspection to check to see if the service had made the required improvements identified. We also reinspected all other areas as the service received a ‘requires improvement’ rating at the last inspection. We were satisfied suitable action had been completed regarding the requirements we made.

People told us they felt safe at the service and with the staff who supported them. People told us, “Yes (I am safe), I cannot say there is anything to worry about,” and a relative told us “We feel that the service is safe.”

People told us they received their medicines on time. Medicines administration records were kept appropriately and medicines were stored and managed to a good standard.

Staff had been suitably trained to recognise potential signs of abuse. Staff told us they would be confident to report concerns to management, and thought management would deal with any issues appropriately.

Staff training was delivered to a good standard, and staff received updates about important skills such as moving and handling, and health and safety at regular intervals. Staff also received training about the needs of people with dementia. Nursing staff had received training in respect of their professional development..

Recruitment processes were satisfactory as pre-employment checks had been completed to help ensure people’s safety. This included written references and an enhanced Disclosure and Barring Service check, which helped find out if a person was suitable to work with vulnerable adults. Staff received a comprehensive induction.

People had access to medical professionals such as a general practitioner, dentist, chiropodist and an optician. People said they received enough support from these professionals. However, examples of when people had attended dental appointments were variable. The registered manager said she would look into this, as the dentist did see people regularly.

There were enough staff on duty and people said they received timely support from staff when it was needed. People said call bells were answered appropriately and we observed staff being attentive to people’s needs.

The service had a programme of organised activities. An activity organiser was employed, although at the time of the inspection she was on maternity leave. Activities currently provided included group table top games such as dominos, singing and baking. External entertainers such as musicians and singers visited on a regular basis.

Care files contained information such as a care plan and these were regularly reviewed. The service had appropriate systems in place to assess people’s capacity in line with legislation and guidance, for example usi

On the day of the inspection we spoke with people who lived in the nursing and dementia wings of Trefula House, to seek their views of the service provided. We were also able to speak with some people’s relatives. Everyone we spoke with was very positive about the care and support they or their relative received. For example one person who used the service said “We are well looked after…anything we need we ask for we usually get”. Another person said “ the staff are very good…they are very nice people.” We concluded people who used the service were treated with respect and dignity, their care and welfare was managed to a high standard, and the staff worked with people to a high professional standard.

Accommodation was decorated, furnished and maintained to a satisfactory standard, although some areas were in need of upgrading. When we inspected the home was clean and odour free. A satisfactory system was in place regarding staff recruitment checks. Staff training needed to be improved. Staffing levels were judged as satisfactory although some people commented these could be improved. Overall quality assurance systems were satisfactory.

We reviewed all the information we hold about this provider, carried out a visit on 28 August 2012, observed how people were being cared for, talked with people who used services, talked with staff, and checked records. We were accompanied by an expert-by-experience (a person with or without formal qualifications, but who has relevant experience by virtue of having received or provided care from/to others).

Some of the people that lived at Trefula House were unable to tell us about their experiences. We did speak to people who lived at Trefula House, and a visiting healthcare professional. All the comments we received from people who lived at Trefula House were positive.

We spoke to two relatives of people that lived at Trefula House. Comments from these people included “[staff are] really brilliant”, “the staff are like a group of friends” and “I can’t think of anything they could do better”.

A GP told us that they thought people had a “reasonable quality of care” and that staff made “good judgements as to when to call other health professionals”. The GP confirmed they had no concerns about care provision at Trefula House. A representative of the local Health Authority confirmed that there were no current concerns about the home.

Comments received from people that live at Trefula House confirm their confidence in the care workers and the manager. People commented on the kindness and politeness of the care workers.

A representative from the Department of Adult Care and Support (DACS) told us that “there are no current concerns about this service”.

Trefula House is a care home which provides accommodation for people who require nursing or personal care for up to 38 people. At the time of the inspection 38 people were using the service. Some of those people were living with dementia. Some people had mental health needs, 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 Trefula House on 13 and 14 July 2015. The inspection was unannounced. The service was last inspected in April 2013. The service was non-compliant with the regulations. However in November 2013 the provider supplied us with information that assured us suitable action had been taken to meet the regulations.

We had concerned there had been eight incidents, in the last month, where medicines were signed as administered but available records did not show that they had been given. We did not see any evidence of regular internal audit of the medicines system. Records showed not all nursing staff had received up to date training regarding medicines management. The medicines system therefore did not operate effectively.

The registered provider offered staff a wide range of training. However, records showed staff did not always receive training, or relevant updates, in a timely manner, as required by health and safety law, professional guidance and company policy. Staff said management were supportive and approachable.

People told us they felt safe at the service and with the staff who supported them. People told us “The staff here are very good, very nice,” and “Yes I am safe, I am well looked after.” A relative told us: “I am impressed; the staff are friendly and kind.”

Most staff had received suitable training and guidance about how to recognise potential signs of abuse and the subsequent action they would take.

Recruitment processes were satisfactory and appropriate pre-employment checks had been completed to help ensure people’s safety.

People had access to a general practitioner (GP), and other medical professionals such as a dentist, chiropodist and an optician. However records of some medical support were not always consistently kept to a good standard.

There were satisfactory numbers of staff on duty to keep people safe and meet their needs. People who used the service, and staff who worked at the home, said there were enough staff provided. For example people who used the service said if they pressed the call bell staff responded to them in a timely manner.

The home was clean and suitable laundry measures were in place. Suitable health and safety procedures were in place to ensure risks were kept to a minimum. The building had been suitably adapted to meet people’s needs. The building was homely, although, in the general nursing wing, some of the decorations and carpets in the hallways and lounges looked worn.

People who used the service told us staff were kind and caring, worked in a respectful manner and did not rush them. For example we were told “I receive excellent care, the food is good and I have no concerns.” 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. Some activities were available for people.

Care files mostly contained suitable information such as a care plan and risk assessments, and these were regularly reviewed. People’s capacity to consent to care and treatment was suitably assessed in line with legislation and guidance.

People said they enjoyed the food, and we were told regular drinks were provided. People had a choice of eating their meals in the dining room or their bedrooms.

Nobody who we met raised any concerns about their care. Everyone we spoke to 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. All the people, who lived in the home, who we spoke with were very positive about the support they received from staff, and about staff attitudes. Family members were also very positive for example describing care standards as “excellent” and staff as “friendly and kind.” There were satisfactory systems in place to monitor the quality of the service.

We found two 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.