This unannounced comprehensive inspection took place on 31 May 2017. The last comprehensive inspection took place on 30 June 2015 we found a breach of the legal requirements at this inspection. It was not clear from the medicine records if some people had received their prescribed medicines, the safeguarding adults policy required updating and accidents and incidents were not formally audited. Identified risks in people’s care plans did not always have guidance for staff on how to reduce such risks. Following the inspection the provider sent the Care Quality Commission an action plan outlining how they would address the identified breach. A focused inspection was carried out on 27 February 2017 to check on the action taken by the provider to address the concerns found at the previous inspection. The service had taken appropriate action to address the breach of regulations and was found to be meeting the regulations at that time.

Tregolls Manor is a care home which offers care and support for up to 25 predominantly older people. At the time of the inspection there were 20 people living at the service. Two people were staying for a short respite period. Some of these people were living with dementia.

People told us, “I am very happy here, I feel safe and cared for” and “I have no concerns at all the staff are all wonderful.”

Families told us, “It is like a five star hotel, it does not feel anything like a care home, it always smells lovely” and “They provide immense dignity for people, hiding away anything that looks clinical.”

Some people living at the service were living with dementia, had very poor sight but were able to move around independently. Toilets, bathrooms and people’s bedrooms were marked with small brass plates with words or numbers only. There was no pictorial signage throughout the service to support people who required additional prompts to recognise their surroundings. There were no supportive handrails in the corridors or gates over open stairways to support people who had been identified as being at risk from falls. Families told us they did not consider this was an issue as their relatives were able to find their way around the building without difficulty. We discussed this with the registered manager who assured us people’s individual needs would be monitored and any additional adaptations required would be discussed with the provider.

The registered manager held a record of staff training, showing when staff had attended specific training. Some staff were due updates on mandatory annual training such as fire safety, moving and handling and health and safety. These updates were scheduled to take place in the planned training programme

We reviewed the Medicine Administration Records (MAR). We found it was mostly possible to establish if people had received their medicines as prescribed. We found some gaps in these records were there was no signature against the time when a medicine was due to be given. Regular medicines audits were consistently identifying when such errors occurred and these were taken up with individual staff. This had led to a reduction in such issues.

Staff were supported by a system of induction training, supervision and appraisals. People were supported by staff who knew how to recognise abuse and how to respond to concerns. Risks in relation to people’s daily lives were assessed and planned for to minimise the risk of harm. Staff meetings were held regularly. These allowed staff to air any concerns or suggestions they had regarding the running of the service.

The service was well decorated, comfortable and clean. There was a programme of regular maintenance and re-decoration of the building. People were treated with kindness, compassion and respect.

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

People's rights were mostly protected because staff acted in accordance with the Mental Capacity Act 2005. Th

We carried out a comprehensive inspection on 30 June 2015. A breach of the legal requirements was found. This was because the arrangements in place for the assessment, monitoring and mitigation of risks were not robust. Some aspects of medicines management were not always effective and accidents and incidents which occurred at the service were not audited to help reduce the risk of re occurrence.

After the comprehensive inspection the registered provider wrote to us to say what they would do to meet the legal requirements in relation to the breach. As a result we undertook a focused inspection on the 27 February 2017 to check they had followed their plan and to confirm they now met legal requirements.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tregolls Manor on our website at www.cqc.org.uk

Tregolls Manor is a care home for up to 25 older people, some people living at the service were living with dementia. At the time of the focussed inspection on 27 February 2017 there were 23 people living at the service.

There was 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.

At this focused inspection we found the registered provider had met the legal requirements of regulations. Medicines were being regularly audited and any concerns were being taken up with specific members of staff. Risks were being identified, assessed and reviewed regularly in order to take account of any changes. Accidents and incidents were being recorded appropriately and audited to help identify any patterns or trends and reduce the risk of re occurence.

This inspection took place on 30 June 2015. The last inspection took place on 19 December 2013. The service was meeting the requirements of the regulations at that time.

Tregolls Manor is a care home which offers care and support for up to 25 predominantly older people. At the time of the inspection there were 22 people living at the service. Some of these people were living with dementia.

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.

People told us; “I am here following an accident just till I am better, it is first class, could not be better” and “Staff are kind and I am happy here.” One family told us; “From the moment we arrived we were cared for, as well as Dad, it has been amazing,” “They really care here” and “I have overheard staff chatting with (the person) in their room as I was just about to go in, it was lovely, just very caring and plenty of time, its just the model of what all homes should be like.”

Visiting healthcare professionals told us; “Fine, everywhere could do with more staff and this is no exception, but here (Tregolls Manor) they are very accommodating and follow our advice, they are good at providing good pressure area care, I have no concerns” and “They are very caring, I am happy with what they provide for patients.”

We looked at how medicines were managed and administered. We found most people received their medicine as prescribed. The registered manager told us they had found “a few gaps” in the medicine administration records in the past, and we found six during this inspection. The registered manager had not recorded their audit of the medicine records, or the action taken to address the concerns. People who self administered their medicines had signed a disclaimer form for this purpose, but had not been specifically assessed and reviewed regularly to help ensure they were safe to manage their own medicines. This meant the service could not ensure people remained able to safely manage their own medicines.

Risk assessments in people’s care files had not been regularly reviewed. Accidents and incidents were recorded at the service. However, the information relating to individual events was held together in one place, which did not comply with the guidance in the Data Protection Act 1998. No audit had been undertaken to help recognise and reduce potential re-occurrence of accidents. One person was exhibiting behaviour that could challenge other people at the service, their visitors and staff. Whilst there was clear information in the person’s care file for staff on how to respond to such challenges, there was no information to advise staff on what action should be taken to try to reduce the risk of incidents taking place.

The service had not recorded the action which they had taken to support people who lacked the mental capacity to make decisions for themselves. People’s capacity was assessed and best interest meetings had taken place for some people.

Policies and procedures held at the service had not been reviewed since 2011 and did not always hold current information for staff to advise them when required. However, most staff were well informed and some current information was available to staff elsewhere in the service such as the staff noticeboard.

The service had sufficient numbers of staff to meet people’s needs and these were being met.

Staff were supported by a system of induction training and supervision. Regular training specific to the needs of people using the service was being provided. Staff were respectful and protected people’s privacy. Care was provided in a calm and patient manner.

Staff meetings were held regularly. These allowed staff to air any concerns or suggestions they had regarding the running of the service.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate and drank to help ensure they stayed healthy.

Care plans were well organised and contained information to inform and direct staff on how to meet people’s needs. Care planning was reviewed regularly and people’s changing needs recorded. However, the review process was evidenced by a signature and a date. There was no documentation to show how people or their relatives were involved in their own care reviews.

Activities and daily trips out from the service were provided for people. People enjoyed the arrangements provided for them.

People received care and support that was responsive to their needs because staff had a good knowledge of the people who lived at the home.

The registered manager was supported by the providers representative and the head of care. However, the registered manager did not receive formal supervision. People, relatives and staff told us the registered manager was approachable, supportive and friendly. Comments included; “The manager is very approachable,” “The manager has arranged everything I have needed,” “Very helpful” and “There is a nice atmosphere here (Tregolls Manor), it is calm.” A visiting healthcare professional told us: “I have always found the manager to be very professional.”

There were systems in place to monitor the quality of the service provided. Audits were carried out over a range of areas, for example fire equipment, lighting, water and cleanliness of the service. Moving and handling equipment and lifts were serviced regularly to ensure they were safe to use.

There was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we told the provider to take at the back of the full version of this report.

At the time of the inspection there were eighteen people living at Tregolls Manor. During our inspection we spoke with eight people who use the service and two relatives. We also spoke with nine members of staff and looked at all people's care records.

People who use the service told us the staff were kind and very good. One person told us, " The care couldn't be better, food is good, I'm happy".

Another person when asked if they could do better by the manager replied, "Don't think you could, it's a dream".

People told us they had no complaints and were able to speak to the manager if they did. People were happy with the food and choices.

We found that staff received training that enabled them to meet people's needs. The home was clean, there were systems in place to minimise infection.

The provider had quality assurance systems in place that ensured people were safe and changes could be made to improve the service provided.

All the relatives that we spoke to made positive comments about the care people received.

We asked staff's views about working at Tregolls Manor. One member of staff told us, "We have enough time to give care, that's what I like about it here".

On the day of the inspection, we spoke with sixteen of the people who lived at Tregolls Manor. People were extremely positive about the care and support they received. For example one person said “I am very happy, I do not think one could find a better home…I cannot fault it”. Other people we spoke with all made similar remarks. People said the food was to an excellent standard, the home was always warm, clean and they felt safe living there. People said that staff were supportive and responsive to their needs.

The home was furnished and decorated to a high standard although some of the paint work and decorations were beginning to be in need of refreshment. However the registered manager said the owner had a plan to decorate some of the communal areas. The bedrooms were decorated and furnished to a good standard. Health and safety standards were generally to a good standard.

When we inspected the home was clean and odour free. Staffing levels were to a good standard. There was evidence that suitable recruitment checks were completed. There were some gaps in records regarding the provision of training. Staff however were observed working professionally with the people living in the home. Quality assurance systems were satisfactory.

We spoke to several people using the service and they said they were very comfortable and happy living in the home. They said the home was well maintained and kept very clean.

They all said the staff were kind and caring and their needs were met. They said there were enough staff and there was someone in charge each day.

They told us the food was excellent and they could have alternatives to the menu if they wished. They said that drinks were always provided and refreshed every day.

They told us they had no complaints but could easily raise issues with staff or the manager if the need arose.

Comments included “It’s fantastic here”, “If you say it’s alright, I’d say it’s very alright”, “I am treated like a queen”, “Nothing is too much trouble”, “The home is always spotless” and “The cleaning staff take a lot of pride in their work”.