We carried out an unannounced inspection of Trevarna on 28 November 2018. Trevarna is a care home with nursing which provides care and support for up to 53 predominantly older people. People living at Trevarna had physical health needs and mental frailty due to a diagnosis of dementia. At the time of this inspection there were 52 people living at the service. At the last inspection in July 2016 the service was rated Good. At this inspection the service remains overall Good.

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.

Trevarna is a single storey purpose built service. It is a service divided into five separate domains known as ‘households’, each named after a flower. They all contain an open plan living and dining area with people’s rooms leading off the main connecting corridors. There is a secure central courtyard garden and side garden area. There are fifteen en-suite facilities and there are sufficient numbers of bathrooms and toilets. Some bathing facilities had been modified to support people who had restricted mobility.

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 and associated Regulations about how the service is run.

Since the previous inspection in 2016 the service had developed a model of care specifically designed to promote quality of life outcomes for people living with dementia and a mental health diagnosis.

Without exception families told us the service was the best place for their relatives to live. Comments included, “I know [relatives name] gets the best possible care at Trevarna” and “I have total piece of mind as soon as I leave that [relatives name] is being well looked after. I can stay and that’s made such a difference for us.” A professional told us, “The manager and staff are totally committed to doing their very best for my clients.”

The registered manager was committed to ensure the services management systems were completely effective by completing auditing systems and acting swiftly to address any identified issues. They spoke passionately about their commitment to the development of the service and had oversight of care provision, service quality and everyone's safety.

Since the last inspection staffing levels had been reviewed. In response to feedback and an analysis of incidents an additional shift had been created to make sure people’s needs were being met in a timely manner. Staff were deployed effectively within the service.

Staff completed a thorough recruitment process to ensure they had the necessary skills for their role. Formal systems for supporting care staff were in place.

Risks to people were assessed and actions were identified and implemented to keep people safe. Staff understood people's psychological and emotional needs and appropriate support was provided to meet them.

People had regular access to healthcare professionals and staff worked collaboratively with them.

Safeguarding procedures were in place and staff had a good understanding of how to identify and act on any allegations of abuse.

People's medicines were managed and administered in line with best practice and staff had received medicines training and their competency had been assessed.

Staff understanding of ensuring people’s legal rights were protected had improved because staff had been trained and supported by the management team to understand the legal requirements of the Deprivation of Liberty Safeguards (DoLS). Most people lacked the mental capacity to recognise the decl

We carried out this unannounced inspection of Trevarna on 24 May and 7 June 2016. The previous focused inspection in January 2016 found there was a breach of regulations. This was because the service did not always have the necessary information to accurately monitor people’s nutrition and hydration. At this inspection we found improvements had been made in this area and the service was now meeting the relevant requirements’.

Trevarna is a care home with nursing that provides residential care for up to 53 people. At the time of the inspection there were 49 people using the service. Most people who lived at Trevarna required general nursing care due to illness. Most people also had dementia, physical or sensory disabilities. .

The service is required to have a registered manager and at the time of our inspection a manager was progressing through the registration process. 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.

The service had reviewed and made changes to ensure monitoring of people’s nutrition and hydration had improved. People were offered a choice of healthy and nutritious meals and staff were familiar with people’s specific likes and dislikes. The cook had information about people’s dietary needs and special diets. Staff supported people to eat meals where they needed help.

Systems were in place to record safeguarding concerns, accidents and incidents and take necessary action as required. Staff had received safeguarding training and understood their responsibilities to report any unsafe care or abusive practices.

Procedures were in place to ensure medicines were managed safely. Staff responsible for the administration of medicines had received training to ensure they had the competency and skills required. Additional training had been delivered to senior care staff to support nurses when administering medicines. Medicines were safely kept and appropriate arrangements for storing were in place.

The service had reviewed the way it was staffed and had made changes to increase staffing levels at the busiest times of the day. This ensured there were enough staff on duty to respond to people’s needs.

Staff working at the service understood the needs of people they supported so they could respond to them effectively. Staff had been trained and had the skills and knowledge to provide support to the people they cared for. One staff member told us, “The training is really good here. I get reminded when my training needs updating.”

The manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). This meant they were working within the law to support people who may lack capacity to make their own decisions.

Visitors reported good relationships with the staff and that the management team were approachable. Families told us, “They (staff) are so patient and caring, we couldn’t ask for better care for (person’s name)” and “I visit a lot and am always made to feel welcome.”

Staff recruitment files contained the relevant recruitment checks, to show staff were suitable and safe to work in a care environment, including Disclosure and Barring Service (DBS) checks. The recruitment process took account of the skills and knowledge required, to provide care to meet people’s needs. There were enough skilled and experienced staff to help ensure the safety of people who used the service.

People told us they knew how to complain and would be happy to speak with the manager if they had any concerns. One person said, “I am more than confident I would be listened to if I was not happy with anything.”

There were systems in place to assess and monitor the quality of the service. Meeti

Trevarna is a care home that provides nursing care for up to 53 older people, some of whom had a diagnosis of dementia. On the day of the inspection there were 50 people living at the service.

The service is divided into five units each individually staffed. Trevarna is a single storey building.

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 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. However, another service manager was deputising in the registered manager’s absence.

We previously carried out a focused inspection of Trevarna on 1 September 2015. At that focused inspection we checked to see if the service had made the required improvements identified at the comprehensive inspection on 10 March 2015. This related to the way the service was staffed. Inspection improvements had been made to the way staff were deployed around the service. However where people required food and fluid monitoring their records were not being maintained to show an accurate record. This resulted in a breach of regulation. The service responded to the breach by providing the commission with an action plan showing what action had been taken to address the breach.

We carried out this focused inspection in response to concerns that the service was not adequately staffed to meet people’s needs. This included staff not having time to complete records and people that required supervision not having the support they required at all times. There were also concerns the manager was not responding to information of concern relayed by staff members.

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

At this focused inspection peoples' fluid and nutrition were being managed had been reviewed and changes put in place to monitor them more effectively. Regular reviews were taking place so that the records were effective and meaningful. However, improvement was still required to ensure all staff were informed of who required monitoring and that the assessed daily amounts of fluid were included in all records, to inform staff and act as a key indicator for them to follow.

There was a deputising manager in post as well as a new deputy manager and they, together with the clinical lead, were continuing to support staff through leadership and operational changes.

People’s health needs were being individually managed and staff had the skills to recognise when people may be a risk of their health deteriorating. People had access to healthcare professionals including GP, chiropodist, dentist and optician.

Staffing levels were continuing to increase and the deployment of staff in each unit had increased since the focused inspection in September 2015. There had been a number of nursing and care staff employed at the service who were currently going through an induction process before commencing work in the service.

There was a current review taking place to introduce a different shift pattern. This would increase staff levels into the evening thereby supporting night staff during the early part of the night shift when some people required more support.

Where people did not have the capacity to make certain decisions the service acted in accordance with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Applications had been made for potentially restrictive practice to be authorised, as

appropriate.

Procedures were in place to assess and monitor the quality of the servic

We previously carried out a comprehensive inspection on 10 March 2015, at which time we made a recommendation about the way the home was being staffed. This was because the deployment of staff was not always suitable to meet the needs of people living at the service. Staff said there were times when people were on their own in lounge areas because they were attending to the needs of individuals. Some people had to wait for care to be provided at times.

During the previous inspection we observed some people’s dignity was not always being respected. A staff member was observed applying cream to a person’s leg whilst sitting in the lounge, in view of other people. In another instance we observed a person sat in their room partially clothed and the door open.

Since the comprehensive inspection of 10 March 2015 the commission received information about concerns relating to the service. These concerns were looked into during this focused inspection. They related to a person’s weight being inaccurately recorded. Staff not having time to assist a person with their meal. Not enough staff available to meet people’s needs and a lack of activities and suitable stimulation for people living at Trevarna. Staff not using mobility equipment safely.

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 Trevarna on our website at www.cqc.org.uk.

Trevarna is a care home with nursing for up to 53 predominately older people. The majority of people were living with dementia. At the time of the focused inspection on 1 September 2015 there were 51 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.

People’s weight, nutritional and hydration needs were being reviewed regularly and acted upon by staff. Where necessary people were referred to other healthcare professionals to assess how best to meet a persons nutrition and hydration. However, individual nutrition and hydration records were not always accurate to reflect what the person had eaten or drank and how much. There were gaps in records without a reason being given.

The development of activities for people using the service since the previous inspection had not improved significantly, to show people were benefitting from a range of activities suitable to meet their needs. We have made a recommendation about the development of activities.

The deployment of staff in the individual units had been reviewed and by recruiting more nursing and care staff the level of staffing had increased. However, incidents of sick leave, was at times resulting in staff covering shifts to maintain a balance of staff in each unit. Recruitment remained on-going therefore staffing levels were increasing at the service.

Staff had received updated training about how to ensure a persons privacy and dignity was being upheld. Observations we made confirmed staff were ensuring personal care was being provided in peoples own rooms with doors closed. Staff told us, “It’s one of the things we go through as part of the induction training” and, “As a senior it’s something I always look out for”.

Staff were observed to be using hoist equipment during the inspection visit. It was carried out by two staff who were competent and confident in using the equipment. A member of staff said, “I have had my training in moving people and using the hoist. It was part of the induction training”.

We found a Breach 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 inspected Trevarna on 10 March 2015. The previous inspection took place on 11 September 2014. The service was meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Trevarna provides nursing care and support to predominately older people who have a diagnosis of dementia. The service can accommodate up to a maximum of 53 people. There were 51 people living at Trevarna when we inspected the service.

The manager in post had made an application to the Commission to register, in order to meet the requirements of the conditions of registration at the location Trevarna. 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.

A staff recruitment programme was underway but some staff members told us that currently there were times when they found it difficult to attend to the needs of individuals. We have made a recommendation about the way staff were being deployed in the service.

Each of the five ‘wings’ at Trevarna had individual kitchen areas for staff to prepare snacks and drinks. We were concerned to see staff washing crockery and cutlery by hand and drying them with a tea-towel. If not managed then this method of cleaning communally used items could become a source of cross infection. Staff told us dishwashers had previously been in place but these had been removed as they broke down. The registered manager and director of operations were informed and said dishwashers would be reinstated to ensure an effective system to manage infection control was in place.

We observed staff applying cream to a person’s leg whilst sitting in the lounge in full view of other people. Shortly after staff assisted the person to their room for more personal care. In another instance we observed a person sat in their own room with just continence items on and the door wide open. This showed people’s dignity was not always being protected.

People were involved and consulted with about their needs and wishes. Care records provided information to direct staff in the safe delivery of people’s care and support. Records were kept under review so information reflected the current and changing needs of people.

Staff were positive about their work and confirmed they were supported by the management team. Staff received regular training to make sure they had the skills and knowledge to meet people’s needs.

Suitable arrangements were in place to protect people from the risk of abuse. People told us they felt safe and secure. Safeguards were in place for people who may have been unable to make decisions about their care and support.

We looked at how medicines were managed and found appropriate arrangements for their recording and safe administration were in place. Records were complete and accurate and medicines could be accounted for because their receipt, administration and disposal were recorded accurately.

Recruitment and selection procedures were in place to ensure people were supported by suitably qualified and experienced staff. Staff records contained all the necessary checks prior to employment to ensure staff were suitable to work with vulnerable people.

The management team used a variety of methods to assess and monitor the quality of the service. These included satisfaction surveys, ‘residents meetings’ and care reviews. Overall satisfaction with the service was seen to be very positive.

We found a Breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulations 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.

This inspection was undertaken to review improvements the provider had made following the previous inspection undertaken on 03 June 2014. During that inspection we found people’s continence needs were not being managed effectively. The management of people’s hydration was not always being recorded in a way which would enable effective monitoring. Hygiene procedures were not always being followed in line with infection control guidance.

Concerns had been received by the Commission that people were being assisted to get up in the morning before they were ready to or chose to.

Is the service safe?

When we inspected this service in June 2014 we found the home was not managing people’s continence needs effectively. During that inspection we also found the service had not been managing the hydration needs of some people, by not accurately recording hydration and therefore having the potential to put people at risk. We looked at what action had been taken to address these areas. The service had implemented new records to record and monitor people’s food and fluid management and had made the situation safe.

Staff were on duty in numbers that met the basic needs of people living at the home at the time of the inspection. However a current organisation staffing review had identified the need for additional staff to ensure people were safe and receiving care and treatment from staff in numbers to meet the individual needs of the people living at Trevarna.

There had been some restrictive practice in place involving the use of stair gates. This had been used to protect people from disturbance in their rooms by residents with dementia care needs. Whilst this issue had been assessed in a ‘best interest’ assessment under the Mental Capacity Act 2005, there was no specific evidence of the decision making process as to why restrictive stair gates had needed to be used. Following discussion with the current manager it was agreed the reason for the stair gates was no longer an issue. Since the inspection visit the inspector has been informed of their removal and was told that revised risk assessments were in place for these residents.

When we inspected the home in June 2014 we found a number of breaches in infection control management within the home. We looked at what action had been taken to address these issues. There had been improvement in cleaning schedules. Domestic staff and care staff had clear roles and responsibilities in respect of the cleaning of commodes. The home was seen to be generally clean and free from odours other than a lounge with a heavily stained carpet. This had been noted and addressed by the maintenance team and was to be replaced in the near future.

Staff we spoke with were knowledgeable about infection control and the importance of following current guidelines. A recent inspection of the sluicing facilities by the maintenance coordinator, confirmed additional wash hand basins had been ordered which would provide staff with the necessary facilities to ensure infection control measures were in place.

Is the service effective?

In order to ensure people received access to a range of supporting healthcare services, staff reviewed when health checks were due. People we spoke with told us, “I see the doctor when I need to. They sort it all out for me”. Also, “They got my appointment at the hospital organised and made sure I was there in time”.

Improvements in the way people’s continence needs were being met and monitored ensured they were effective and changes made where the need was identified.

Improvements to the way infection control measures were being managed ensured they were effective. Necessary equipment was in place including protective clothing and cleaning materials, as well as ensuring staff training in infection control was up to date.

Staff we spoke with had an understanding of people’s needs and how to deliver care and treatment for people they were supporting. One staff member told us, “We are responsible for keeping the information up to date. It’s really important because people’s needs change so quickly sometimes”.

Is the service caring?

People were treated with respect and dignity by the staff. People told us they felt safe. One person told us, “Everyone is so kind and helpful”. Another said, “It’s not like home but I feel safe here, there is always someone around for me”.

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People we spoke with told us, “They are so very patient with me, and it’s nice to feel cared for”.

Is the service responsive?

The service worked with other agencies including social services, nurses and healthcare professionals to make sure people received care and support in a coherent way. This meant people received the right care and support to meet their individual needs and remain as independent as possible.

Is the service well led?

The inspection in June 2014 identified non- compliance in areas of care and welfare and infection control. This inspection identified what action had been taken by the management team to improve those areas.

Staff did not always feel supported by the management team when concerned about staffing issues. Effective communication with the staff team either through meetings or by other methods would allay concerns relating to changes occurring.

There were a range of audits and systems put in place in by the manager and provider to monitor the quality of the service being provided.

During our responsive inspection of this service we used the evidence gathered in relation to the three outcomes we inspected to answer three of our five key questions; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? We have responded to the three questions below.

Below is a summary of what we found. The summary is based on information gathered during our inspection which included conversations with people who used the service, relatives, staff and the management of Trevarna.

Is the service effective?

On the day of the inspection we judged the service was effective because all of the people we spoke with who received care from Trevarna were happy with the quality of care they received. People told us “I am happy here” and the staff are “marvellous”. We also saw that people’s care planning documentation accurately reflected people’s medical and psychological needs to enable the home to meet these needs. We saw that staff were aware of peoples’ needs and that they delivered the support that they were instructed to.

Is the service caring?

On the day of the inspection we judged the service was caring because people told us their relatives were well cared for by staff. Their comments included “nothing is too much trouble”. We heard staff talk with the people who lived at Trevarna in a caring manner. In addition we saw staff caring for the people that used the service, including seeing people laughing and joking with staff. We also spoke with two people who were visiting their relative and they told us, “the attitude towards clients is brilliant” and “nothing is too much trouble”. One member of staff told us “It’s lovely here, we are like one family”.

Is the service responsive?

On the day of the inspection we judged that the service was not responsive because the physical needs of people who lived at the home were not always being addressed appropriately. Fluid intake, for people at risk of illnesses associated with dehydration, was not documented appropriately and was not being monitored adequately. We also noted that there had been some failures in communication between the care staff and the staff in charge. However we did see that in the vast majority of cases people had been supported to access medical services in a timely fashion and were referred appropriately if a person’s needs changed.

In addition infection control procedures and practices were not addressing the present cleansing of commode pots practice in the home. Therefore the home was not ensuring that both the staff, and the people that lived at Trevarna, were adequately protected against the associated risks.

We previously inspected this service in October 2013. The Commission issued three compliance actions as the service had been found to be non-complaint with the Essential Standards of Quality and Safety relating to respecting and involving people who use services, staffing and record keeping.

As part of our inspection we spoke with the deputy manager, clinical deputy manager (lead nurse), care staff and laundry staff. Since our previous inspection of Trevarna the home had been working to make improvements to become compliant with the Essential Standards of Quality and Safety.

During our inspection we observed staff were kind and empathetic towards people, and spoke to them in an adult to adult and respectful manner.

Procedures had been and were being put in place to improve and protect peoples' privacy and dignity.

Care plans were detailed and we saw they were updated in line with the information in care reviews. Work was underway to further improve recording standards.

We saw staff were busy and they told us they were currently meeting people’s physical and care needs. We saw that seven additional staff had been employed. This was so time could be allocated to meet peoples’ emotional and social needs.

We did not speak to people who used the service due to their various health needs.

We carried out this inspection between 17:00 and 21:30 as the Care Quality Commission had received concerns about staffing levels at Trevarna, particularly during evenings and nights.

During our inspection we observed staff were kind and empathetic towards people, and spoke to them in an adult to adult and respectful manner.

Peoples' privacy and dignity was not always protected.

Care plans were detailed, but sometimes we saw they were not updated in line with the information in care reviews.

We saw staff were busy and they told us they were currently managing to meet people’s physical needs. However they did not always have time to meet peoples emotional and social needs.

Staff we spoke with said they felt well supported by management.

Some of the people that lived at Trevarna were unable to tell us about their experiences.

We spoke to three people who lived at Trevarna and all the comments we received were positive. One person told us, “I am happy here, they look after me and meet my needs”. Another person told us, “The food is good and the staff are friendly”.

We spoke to two relatives of people that lived at Trevarna. They told us they were satisfied with the care provided and they were informed of the progress concerning the person they were visiting.

People were protected from abuse and staff were trained and supported to carry out their roles.

Staff told us that training was provided, and also confirmed that staff supervision took place.

Care plans and associated documentation provided sufficient detail to direct and guide staff of the action they needed to take in order to meet people’s assessed care needs.

People's records were personalised and provided clear information about the person’s wishes and abilities.

We reviewed all the information we hold about this provider, carried out a visit on 29 and 30 August 2012, observed how people were being cared for, talked with people who used services, talked with staff, and checked records.

Some of the people that lived at Trevarna were unable to tell us about their experiences. We spoke to people who lived at Trevarna and all the comments we received were positive. One person told us, “I am happy here, they look after me and meet my needs”. Another person told us, “ The food is good and the staff are friendly.

We spoke to a relative of people that lived at Trevarna. They told us they were satisfied with the care provided and they were informed of the progress concerning the person they were visiting.

Not everybody at the home was able to tell us what it was like to live at Trevarna. People who were able told us that they liked living at the home. People we spoke with were complimentary about the staff looking after them and the care they received.

People using the service told us they were happy with the standards and choice of food available. People who were able also told us that they could make choices about how and where they spend their day.

We observed that staff appeared to have good relationships with some of the people they care for and demonstrated insight into how to provide care in a thoughtful and appropriate manner. We saw people who live at the home, chatting and laughing with other people who live there and with staff.

People told us that they felt safe and that they had confidence in the management of the home. People, who were able, told us that they felt able to raise any concerns with the staff at the home. One relative told us they had not experienced positive responses to complaints raised.

We have received from the management of Cornwall Care an action plan which details actions taken in response to the compliance and improvement actions made at the planned review. We spoke with the deputy manager to establish what actions had been taken since the last planned review of compliance 31 January 2011. We also visited the home twice as part of a responsive review to follow up the improvement and compliance actions.

Not everybody at the home was able to tell us what it was like to live at Trevarna. We spoke with two people using the service who were able to tell us that they are happy with the care provided and feel part of the process when decisions are made about their care.

We observed staff providing care and saw that they treated people with dignity and respect and included people in the choices about how they provided care. We looked at records relating to three people who live at the home. We saw that whilst the records are detailed in places, they lack sufficient detail in all areas to ensure that new or inexperienced staff could provide the personalised care needed to meet everybody’s needs.

Staff told us that supervision and support for senior staff has been implemented and we looked at records which confirmed this was the case.