We carried out this unannounced inspected on 23 and 24 April 2018. The service was last inspected in January 2016 when the service was rated as ‘Good’. At this inspection we have rated the service as ‘Requires Improvement.’ This was because we had concerns about the robustness of the quality assurance systems, staff understanding of the Mental Capacity Act and the maintenance of the premises.

Treseder House is a ‘care home’ that provides care for a maximum of eight adults with learning and/or physical disabilities. The service is owned and operated by the Royal Mencap Society. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is owned and operated by the Royal Mencap Society and can accommodate a maximum of eight people.

At the time of the inspection there were seven people living at the service. The service is set in a detached house on two floors with access to the upper floors via stairs. One room had en-suite facilities; other rooms shared three additional bathrooms, one of which was specially adapted with a hoist to support people with limited mobility. Shared living areas included a lounge, a dining room, a garden with decking area and patio seating area.

The service had undergone a number of management changes in recent months including a new service manager and an interim Area Operations manager.

The service is required to have a registered manager in post to hold responsibility for the day-to-day running of the service. 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 registered manager had given CQC notice of a period of absence from their position.

Most people living in the service had limited verbal communication and were not able to tell us in depth their views about the care and support they received. However, we observed people were relaxed and comfortable with staff, and they received care and support in a way that kept them safe. People's behaviour and body language showed that they felt cared for and that they mattered. Some people were able to tell us their views and said they felt safe and happy living at Treseder House. It was clear people were comfortable with staff and moved freely around their home.

Support was provided by a consistent staff team who knew people well and understood their needs. Staff were positive about the people they supported and demonstrated a good knowledge of people’s support needs. We saw that staff had good relationships with people and displayed empathy and warmth in their care. Staff comments included, "I believe people have a good life here. We try our best to make them happy" and "The staff seem to be happy and the people we support are happy."

People were encouraged to be individuals and do what they wanted to do to provide them with a fulfilling life. For example, people who could, went out regularly to local community activities, such as day placements. People also left the service for trips supported by staff. There were a range of personalised and appropriate risk assessments in place to help keep people safe.

There were enough staff to meet people’s changing needs and wishes. Staff said they felt supported by managers and received regular individual supervision. There were also regular staff meetings which gave staff the chance to meet together as a staff team to discuss people’s needs and new developments for the service.

The atmosphere at the service was calm and happy. During the inspection we saw people were well supported and took part in their planned activities for the day. This

We carried out this unannounced inspection of Treseder House on 6 January 2016. Treseder House is a residential care home, which provides care and support to people who have a learning disability. The service is owned and operated by the Royal Mencap Society and can accommodate a maximum of eight people.

On the day of the inspection there were eight people using the service. The service was last inspected in March 2015 when we found there were two breaches of regulations under the domains of safe and well-led. We received an action plan from the provider about what action the service would take to correct the breaches.

The service is required to have a registered manager and at the time of our inspection a registered manager was 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 and their relatives told us they were happy with the care and support provided by staff at Treseder House and believed it was a safe environment. One relative said, “We couldn’t be happier with how Treseder cares for (person’s name). We feel fortunate that (persons’ name) has been able to make a home here and this is their home”. A person who lived at the service told us they felt happy living at Treseder House and it was clear people were comfortable with staff and moved freely around their home.

Staff had made positive relationships with people and understood their needs well. People were encouraged to be individuals and do what they wanted to do to provide them with a fulfilling life. For example, those people who could, went out daily to local community activities, such as voluntary work. People also left the home for trips supported by staff. There were a range of personalised and appropriate risk assessments in place to help keep people safe.

The safety of the premises was looked after by the registered manager, who employed a maintenance person to make sure regular maintenance of equipment such as electrical and gas appliances was carried out. This meant the management of the service had done appropriate checks to keep people safe while they were living at Treseder House.

Staff showed by their actions and by explanation that they understood how to keep people safe, including what they should do if a safeguarding issue was raised. Accidents and incidents were recorded and investigated. This meant management could look for patterns in accidents and incidents and take action to reduce these.

Support was provided by staff who knew people well and understood their needs. There were enough staff to meet people’s changing needs and wishes. The service used a care agency to supply more staff at short notice when needed.

Medicines were stored, handled and recorded safely. This meant that people using the service were given the correct medicines at the correct time and this was clearly recorded.

People who lived at Treseder House and relatives we spoke with, said they were confident in the staff group, and that they provided good quality care. Staff demonstrated they were skilled and knowledgeable about their roles. We were told there were opportunities for further training and to obtaining additional qualifications. Staff said they felt supported by management and received regular individual supervision, and appraisal to review their work performance over the year.

Premises were properly maintained with a clean, bright and inviting environment. All living areas were clean and well looked after. During the last inspection we found the area outside the service had some pieces of old furniture left in the garden instead of having been disposed of. At this inspection we saw the garden and grounds around the service had been cleared and were well m

When the Care Quality Commission inspects health and social care services the inspector works to answer five key questions; is the service safe, effective, caring, responsive and well-led?

In June 2014, the Care Quality Commission issued three compliance actions to the registered persons regarding Regulation 17, respect and involvement of people who live at Treseder House, Regulation 10 how effective the provider’s assessment and quality of the service is and Regulation 20 regarding records kept by the provider.

This inspection was completed to check suitable action had been taken to improve compliance in these three areas. As part of this inspection we also reviewed the policy and processes involved in supporting staff.

During the inspection we were able to speak with four people who used the service. We also spoke with four care staff who worked at the home.

Below is a summary of what we found.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

On the day of inspection, we judged the service was safe. The service had addressed the identified areas of non-compliance following the inspection in June. People were provided with feedback opportunities in the form of house meetings, clear complaint procedures and an annual satisfaction survey to allow people to input into the running of the service. However, we did have some concerns about the implementation and recording of staff supervision and appraisal systems which had the potential to negatively impact on the care of people supported at the service.

Is the service effective?

On the day of inspection we judged the service was ineffective. This was primarily because of lack of audit and staff follow-up where medication errors had occurred.

We did find positive changes had been implemented to the care/support plans for people who lived at Treseder Lodge. Improved systems had been implemented to monitor people and ensure people were protected against the risk of inappropriate or unsafe care.

The service had a quality assurance policy and procedure. However, we were unable to review how effective the procedure was as we could not access the quality assurance returns for the three month period which pre-dated the inspection. Staff told us monitoring procedures for following up on medication errors were not consistently implemented and a review of associated reporting documentation confirmed this.

Is the service caring?

On the day of inspection we concluded the service was caring. People told us they were ‘happy’ living at Treseder House. We saw people were treated with respect and care at all times. We saw many examples of positive interactions throughout the day of inspection.

Care records, were up to date and accurately recorded the current situation for each person who lived at the home. There were accurate risk assessments in place to ensure risks were identified and minimised. These were regularly reviewed and staff demonstrated a good level of knowledge about the people they supported.

Is the service responsive?

On the day of inspection we found the service was responsive. We saw clear documentation on care/support plans which demonstrated that when required the service worked effectively with other multi-disciplinary professionals and families to ensure decisions were made in a person’s best interests. Significant work had been undertaken by Royal Mencap’s quality control staff to update records, minimise duplication of records and highlight significant risk where identified, to protect people effectively.

Is the service well led?

On the day of the inspection, based on the evidence we looked at and the responses from people we spoke with, we concluded the service was not well led. This was primarily because quality assurance records did not agree with staff supervision records. Quality assurance information was unavailable on the day of inspection due to the service manager not being at the service and the deputising manager being unable to access quality monitoring information from the computer system. In addition, it was found that following two recorded medication errors, Royal Mencap’s procedure for such incidents had not been followed .

A one day inspection of Treseder House took place on 22 August in order to follow up on publication of two warning notices issued following the previous inspection in June 2014. During the inspection, the inspection team worked to answer three of our five key questions; is the service safe, caring, and responsive. The questions of effectiveness and whether the service is well-led will be dealt with in another report?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We judged the service was safe on the day of inspection.

We spoke with people who lived at the home, spoke with the registered manager and three staff. We also examined key documentation such as care plans, risk assessments and daily records. People told us they felt safe and secure. The people we spoke with were positive about the staff who worked with them.

During our last inspection we saw incidents where vital safety information about a person's risk of choking had not been adequately recorded or monitored to ensure the safety of the person. We saw there were now new risk assessments and care plans in place in relation to a number of individuals who were deemed to be at risk of choking.

We saw prominent risk information displayed at the front of care plans which underlined the risk and signposted where further information could be found. We spoke with staff, who were clear about exactly what they should do to safely support each person in the event of a choking event. Staff were required to read and sign their understanding of the contents of risk assessments and care plans in order to demonstrate their understanding of the action required in the event of an emergency.

Is the service caring?

We judged the service was caring on the day of inspection.

We observed kind and patient interactions between staff and the people who were supported. We found care planning did reflect the current needs of people who lived at the home.

Is the service responsive?

We judged the service was responsive on the day of inspection.

We saw evidence that the service had implemented new recording practices and procedures to ensure the care and safety of people who lived at Treseder House.

We met with two people who lived at Treseder House. We also spoke with the registered manager and three staff member and three representatives of people who lived at Treseder House. People spoke highly about the quality of care offered to people who lived at the home and we observed people were happy and liked the staff that assisted them. One person’s relative told us , “I am very happy with Treseder House. X has lived there for a long time and loves it. The staff are all very caring. ” Another relative told us, "I am extremely happy with Treseder House. I couln't praise the management and staff enough for the care they provide to X".

We saw the home was comfortable and clean. We observed each person had individualised their own room to suit their personal taste. People we spoke with told us they were encouraged to choose how they spent their time and had free choice about areas of their life such as when they went to bed and what choice of meals they had. We saw people coming and going from various activities during the day. From our discussions with people who lived at Treseder House, a review of care planning documentation and observations throughout the inspection period we found that people experienced safe and appropriate care and support that met their needs.

We found there were suitable arrangements in place for obtaining, and acting in accordance with, the consent of people who lived at Treseder House in relation to the care and treatment provided for them.

People who lived at the home were safe and their health and welfare needs were met by staff who were appropriately qualified, skilled and experienced.

The provider had appropriate systems in place to regularly assess and monitor the quality of the service.

There was an accessible complaints system in place for identifying, receiving, handling and responding appropriately to complaints.

Treseder House provides accommodation for up to eight people who need support with their personal care. The service mainly provides support for older people living with a learning disability. The service is situated in a detached house arranged over two floors and has eight single bedrooms. There were eight people living at the home at the time of our inspection.

This was an unannounced inspection, carried out over two days on 24 and 25 March 2015. During the inspection we spoke with six people who lived in the home, five staff and three service managers including the area manager, newly appointed service manager and deputising registered manager, who primarily managed another Royal Mencap home in Cornwall. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We last inspected Treseder House in September 2014. At that inspection we found the service was not meeting all the essential standards that we assessed. We found breaches of legal requirements relating to supporting workers and assessing and monitoring the quality of the service. The first breach concerned supervision practices not being consistently carried out. At that time of the inspection in September 2014, we found staff were not consistently receiving supervision and recording practices for supervision did not always reflect Royal Mencap’s policy and procedure in this area.

The second breach concerned ineffective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others because regular auditing of medication processes was not taking place.

At this inspection the newly appointed service manager and deputising registered manager told us staff supervision and appraisal systems had been brought up to date. We reviewed staff files and saw all staff had received recent supervision with the service manager. Staff and management confirmed they had had regular supervision and annual appraisals. We found the service was now meeting the regulations in this area.

We observed care and support in the lounge and dining area, spoke to people, and looked at care and management records. Following the inspection we also spoke with relatives of people living at Treseder House and other professionals who worked with people who lived at the home. Although people told us that they felt safe in this home, we found there had been a number of medication errors affecting people’s medicines. This impacted on the safety and consistency of medicines management at the home.

People told us they felt safe living at the home. Comments included; “I like it here, I am happy”, “Very good. I like everyone” and “Good place to live”. A relative told us, “I really don’t have anything negative to say about Treseder. They have looked after (relative) for a long time and I really couldn’t ask more of them. The staff care and they go the extra mile”.

We walked around the home and saw it was comfortable and personalised to reflect people’s individual taste. We became aware of a strong unpleasant odour in two toilets. We asked the service manager to remove a clinical waste bin from one person’s room due to the strong malodour this was causing. We saw there was a defective thermostatic valve fitted in one bathroom. The defect allowed the water temperature to rise to a temperature of 48 degrees Celsius. High water temperatures, particularly temperatures over 44 degrees Celsius, can create a scalding risk to vulnerable people who use care services. We asked the service manager to put an immediate risk assessment in place to protect the safety of people who used the service, and send CQC an action plan for rectifying this, which was done.

The systems used to assess the quality of the service had identified the issues that we found during the inspection. However, the issues had not been rectified in a timely manner. This meant the quality monitoring processes for the service were not effective as they had not ensured that people received safe care that met their needs.

People were treated with kindness, compassion and respect. The staff in the home took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff in the home. Staff were trained and competent to provide the support individuals required.

Where people did not have the capacity to make certain decisions the home acted in accordance with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People had a choice of meals, snacks and drinks, which they told us they enjoyed. People had been included in planning menus and their feedback about the meals in the home had been listened to and acted on. Comments included; “I like the food, it is very good” and from a relative, “The food is good. People are given a choice and each night one person picks a meal they enjoy and it goes round so everyone has a choice. If they don’t like what is offered people are offered something else. It’s like being in your own home”.

People told us staff treated them with care and compassion. Comments included; “I couldn’t fault the staff. They are so caring. It is clear to see they understand and care for the people here” and “The staff are fine – no complaints.” Visitors told us they were always made welcome and were able to visit at any time. People were able to see their visitors in communal areas or in private. People told us they knew how to complain and would be happy to speak with the registered manager if they had any concerns.

Relatives of people living at Treseder House told us that people, and their families had been included in planning and agreeing to the care provided at the home. We saw that people had an individual plan, detailing the support they needed and how they wanted this to be provided.

The staff on duty knew the people they were supporting and the choices they had made about their care and their lives. People were supported to maintain their independence and control over their lives.

The service did not meet the regulatory requirement to notify the Care Quality Commission about two required areas. The service manager did not notify the Care Quality Commission (CQC) of a disruption to the service by a failure of the gas supply. This meant there was no hot water for a period exceeding 24 hours. Also, the service did not notify the CQC about the absence of the designated Registered Manager for a continuous period of 28 days or more.

The provider had not maintained the environment outside the building. In the garden of the home we saw a number of pieces of old furniture, such as a mattress, that had been disposed of by left outside on the patio area. This did not provide a safe or pleasant environment for people to use.

We found 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 the report.