Trevern is a ‘care home’ that provides accommodation for a maximum of 40 adults, of all ages with a range of health care needs and physical disabilities. At the time of the inspection there were 38 people living at the service. 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.

Trevern is situated in the town of Falmouth. The building is split into three units known as the Wing, The Flats and The House. Each Wing has its own lounge and dining area. People’s bedrooms were personalised and were for single occupancy. Each wing has a range of aids and adaptations in place including bathing facilities, designed to meet the needs of the people using the service. There were people living at the service who were living with dementia and were independently mobile. There was pictorial signage at the service to support some people, who may require additional support with recognising their surroundings. There was a courtyard which people could use.

The last comprehensive inspection took place in November 2017. As the service had breaches of regulation we undertook a focused inspection in January 2018 to review the actions the provider had taken to address the concerns identified. The service was rated as Requires Improvement at that time. There were concerns around staffing levels, a high reliance on agency staff and audits had not been completed to identify where there were shortcomings in the service. We imposed conditions on the providers registration to send us regular updates as to how these issues were to be addressed.

This unannounced comprehensive inspection took place on 29 November 2018. At the last inspection, in January 2018 the service was rated Requires Improvement. At this inspection we found the service remained Requires Improvement.

There was no registered manager in post. Since the last inspection there had been three interim managers in post. The interim manager at this inspection was appointed in October 2018 and was contracted to work until the end of January 2019. The provider had been actively recruiting to this post but no candidate had been appointed.

People told us that they were aware that there had been a number of manager changes at Trevern and were not able to identify who the current manager was. Health and social care professionals were also concerned about the number of management changes. They told us they were not sure who to speak to when they phoned or visited the service as staffing personnel changed. Staff told us that they were “disillusioned” in respect of the lack of constant leadership in the home.

There had also been recent changes to the Cornwall Care Senior management team with a new appointment to the Chief Executive Officer (CEO) and interim operations director. Staff were still uncertain regarding how this change would affect the organisation, but were pleased to have received a newsletter from the CEO introducing herself to the staff.

Staff confirmed that supervision had not occurred regularly. With the appointment of the interim manager and clinical deputy manager this was now being addressed. Staff meetings had also not occurred regularly. This did not give staff the opportunity to voice their opinions or concerns regarding any operational changes to the service.

People were positive about the care they received from staff at the service. However, they told us that there remained a reliance on agency staff. People told us that they were hesitant to call for assistance as they were aware that staff were ‘busy’ or ‘short staffed’. We received a mixed response from people in how quickly call bells were answered. Comments included “I can generally get help when I need it but I know the staff are really busy. Sometimes I say I would like to get up but they have other people to look after and say I’ll jus

We carried out an unannounced focused inspection of Trevern on 25 January 2018. At our previous comprehensive inspections in May and November 2017 we identified breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in respect of the management of identified risks to people’s well-being, gaps in monitoring records and the oversight of the service. As these were repeated breaches we issued warning notices following our inspection in November 2017. At our inspection in November 2017 we also had concerns about the safety of the environment and identified a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following our last inspection the provider wrote to us detailing the actions they planned to take to ensure they were meeting the requirements of the Regulations. We carried out this focused inspection to check they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Trevern on our website at www.cqc.org.uk.

Trevern is a ‘care home’ that provides nursing care for up to a maximum of 40 predominately older people. 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. At the time of the inspection there were 34 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs. Trevern is part of the Cornwall Care group which has several nursing and residential homes in Cornwall.

The service is required to have 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. There was a manager at the service who had been in post since early September 2017. They had recently completed the appropriate checks and were applying to CQC to be registered.

We found the service was highly dependent on agency and bank staff. Although as far as possible, staff who were familiar with the service were used, this was not always the case. Staff told us, even when the service was fully staffed there were not enough care assistants on shift to meet people’s needs in a timely manner. This was more difficult if some of the staff team were unfamiliar with the service and people’s needs. We identified a breach of the regulations.

We still had concerns in respect of the effectiveness of auditing systems. We found gaps in monitoring records used to record when people had received care. Although these records had been audited the gaps had not been noted or any action taken to look at why the records had not been completed. Audits to give an oversight of people’s weights had failed to identify when people were not being weighed as often as outlined in their care plan.

Behaviour records had not been completed correctly. This meant potentially relevant information to guide staff to support people in a way which meant they were less likely to become anxious and distressed was not being captured. We concluded the provider had failed to take adequate action to ensure the conditions of the warning notice were met.

Risks to people’s well-being and health were well documented. There was clear guidance for staff to follow to protect people from foreseeable harm. Staff communicated at handover and throughout the day to help

We carried out an unannounced comprehensive inspection of Trevern on 22 November 2017. At our last inspection in May 2017 we identified breaches of the regulations. The breaches were in respect of a lack of personalised information in people’s care records, capacity assessments did not accurately reflect people’s needs, care records did not guide staff on how they could protect people from identified risks and there were gaps in monitoring records.

At this comprehensive inspection we checked to see if the provider had made the improvements necessary to meet the breaches identified at the inspection in May 2017. We found improvements had been made in some of the areas of concern. Capacity assessments were up to date and the processes in place to ensure the service was acting in accordance with the legislation were robust. Progress had been made in terms of gathering personalised information about people’s backgrounds and life histories. We found the service was no longer in breach of Regulations 9 and 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We still had concerns in respect of the management of identified risks to people’s well-being, gaps in monitoring records and the stability of the management of the service. At our last inspection we had also had some concerns in respect of the environment. At this inspection we again found similar concerns. This is the third consecutive time the service has been rated Requires Improvement.

Trevern is a ‘care home’ that provides nursing care for up to a maximum of 40 predominately older people. 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. At the time of the inspection there were 34 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs. Trevern is part of the Cornwall Care group which has several nursing and residential homes in Cornwall.

There was a registered manager for the service. However, they had not worked at Cornwall Care for some time. CQC had not received an application to cancel their registration at the time this report was issued. 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. There was a manager at the service who had been in post since early September 2017.

At our inspection in November 2016 we found a lack of guidance for staff on how to support people who had been identified as being at risk and we issued a recommendation. In May 2017 we again found examples in people's records where a risk had been identified and the care plan did not

contain guidance for staff on how to reduce the risk or meet the person's associated care needs. At this inspection we found staff did not have clear guidance in place on how to care for people who were at risk of developing pressure sores. Although it was recorded when people required repositioning to protect their skin integrity it was not stated how often this should happen. In addition we found that, where a risk had been identified and documented, action was not taken to protect the person in line with care plan.

At our inspections in November 2016 and May 2017 we found there was a lack of stable leadership at the service. At this inspection there was a new manager in the post. They told us they were in the early stages of applying for registration and were committed to the role and driving up standards. However, they had not been in the role long enough for us t

This inspection took place on 24 and 26 May 2017 and was unannounced.

At the previous comprehensive inspection on 21 November 2016 we found breaches in the legal requirements relating to staffing levels, management arrangements, monitoring records, and the security arrangements of the building. Following the inspection in November 2016 the provider sent the Care Quality Commission an action plan outlining how they would address the identified breaches. We undertook this inspection to check the provider had followed their plan and to confirm that they now met legal requirements.

Trevern is a care home that provides nursing care for up to a maximum of 40 predominately older people. At the time of the inspection there were 36 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs.

There was a registered manager at the service who had not been at work for several months. 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. There was a temporary manager in post who supported us throughout the inspection. The temporary manager will be referred to throughout this report as "the manager".

At the previous inspection, the service had identified the minimum numbers of staff required to meet people’s needs. We found these were not being consistently met. The management team had identified there were high levels of staff absenteeism due to last minute sickness and this was contributing to low staffing numbers. Action was being taken to address this issue and a new sickness management policy had been introduced. However, it was too early for us to evaluate the effectiveness of this new policy. At this inspection, we found improvements had been made. We reviewed the rotas held by the service and observed staffing levels. We found that staff were able to respond to people in an unhurried way and call bells were answered promptly. The manager told us the sickness policy worked well and numbers of absenteeism had reduced.

At the previous comprehensive inspection in November 2016, we found that care plans contained risk assessments for a range of circumstances. The assessments were updated regularly to reflect people’s changing needs. However, there was a lack of guidance in place for staff on how to care for someone who had been identified as at risk. We made a recommendation in the previous inspection report about the management of risk. At this inspection, we did not feel that this issue had been adequately addressed. We continued to find examples in people’s records were a risk had been identified and the care plan did not contain guidance for staff on how to reduce the risk or meet the person’s associated care needs.

At the previous inspection in November 2016, we found that people's health needs were monitored. However, records documenting this were inconsistently completed. There were gaps in records and some had not been dated. This meant it was difficult to establish whether people had received care according to their plan of care. This continued to be a concern at this inspection. We found frequent examples in people’s records where we could not gain an accurate picture of the care people were receiving.

At the previous comprehensive inspection, we found there was a lack of clear oversight of the service. Although some staff had been given responsibility for various areas, for example, rotas and auditing, this had not prevented the problems identified at this inspection from occurring. An interim manager was in place but they had not gained a good working knowledge of the service. Re

This comprehensive inspection took place on 21 November 2016 and was unannounced. The last inspection took place on 30 June 2015 when we identified a breach of the legal requirements relating to staffing. Staffing levels defined as necessary for the service were not consistently met and there was an overreliance on agency staff. Following the inspection in June 2015 the provider sent the Care Quality Commission an action plan outlining how they would address the identified breach. After that inspection we received concerns in relation to staffing levels, management arrangements, monitoring records, and the security arrangements of the building.

We undertook this inspection to check the provider had followed their plan and to confirm that they now met legal requirements. We also looked at the areas that had been raised to us as concerns.

Trevern is a care home that provides nursing care for up to a maximum of 40 predominately older people. At the time of the inspection there were 36 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs.

The service is required to have 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. Although there was a registered manager in post at the time of the inspection the service was being overseen by an interim manager.

The service had identified the minimum numbers of staff required to meet people’s needs, these were not being consistently met. The management team had identified there were high levels of staff absenteeism due to last minute sickness and this was contributing to low staffing numbers. Action was being taken to address this issue and a new sickness management policy had been introduced. However, it was too early for us to evaluate the effectiveness of this new policy.

Care plans contained risk assessments for a range of circumstances. The assessments were updated regularly to reflect people’s changing needs. There was a lack of guidance in place for staff on how to care for someone who had been identified as at risk.We have made a recommendation in the report about the management of risk.

Systems for the management and administration of medicines were robust. Medicines were stored safely and securely and regular audits were carried out.

Improvements had been made to the environment and more were planned. Some areas were in the process of being redecorated. Arrangements to minimise the effect of the redecorating on people’s daily lives were in now place although previous improvements had not been well planned.

People had access to activities. Two healthcare assistants had additional responsibilities as activity co-ordinators. They organised visits from outside entertainers as well as providing activities themselves. There were also regular trips out to local events and landmarks. People who stayed in their rooms had more limited access to activities.

People's health needs were monitored. However, records documenting this were inconsistently completed. There were gaps in records and some had not been dated. This meant it was difficult to establish whether people had received care according to their plan of care.

There was a lack of clear oversight of the service. Although some staff had been given responsibility for various areas, for example, rotas and auditing, this had not prevented the problems identified at this inspection from occurring. An interim manager was in place but they had not gained a good working knowledge of the service. Relatives were not clear as to the arrangements for managing the service a

This inspection took place on 30 June 2015 and was unannounced. The last inspection took place on 16 January 2015 when we identified breaches of the legal requirements relating to the safety and suitability of the premises and care and welfare. Care and treatment was not planned and delivered in a way that ensured people’s safety and welfare. Care plans were not reviewed to reflect changes in people’s needs. People were not always provided with the correct incontinence products and communally used toiletries were found in all bathrooms. There was very little meaningful activity for people. The environment was in need of some attention. Internal windows were not clean. Items were stored inappropriately in corridors and bathrooms. There was no effective process for assessing and monitoring the risks to people within the premises to identify issues that required attention within the home.

Following the inspection in January 2015 the provider sent the Care Quality Commission an action plan outlining how they would address the identified breaches and concerns. We found the improvements had been made or were progressing in line with the action plan.

Trevern is a care home with nursing for up to a maximum of 40 predominantly elderly people. At the time of the inspection there were 35 people living at the service. Some of these people were living with dementia.

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.

Relatives and external professionals told us the service was often low on staff and it could be difficult to find anyone when people needed assistance. Agency staff was often used to make up staff numbers although these were usually staff who were familiar with the service.

When people’s anxieties resulted in behaviour which staff might find difficult to manage, they were sometimes given medicine to reduce their anxiety. However there was no clear written guidance for staff on when medicine should be administered. This meant there was a risk staff might not take a consistent approach to administering medicine. There were inconsistencies as to when these events were defined by staff as ‘incidents’ which required recording on an incident form. This meant anyone analysing incidents to ascertain any patterns or trends, might not have access to all the relevant information. We have made a recommendation about this in the report.

Staff had received training in safeguarding and were confident of the action to take if they suspected abuse. The registered manager was familiar with local protocols for raising safeguarding issues.

The premises were clean and odour free. Plans were in place to replace the windows in the older part of the service in the very near future. Arrangements had been made to limit any disruption to people during this time.

Staff were friendly and caring in their approach to people. They spoke with people before giving any care or support, informing them of what was going to happen and making sure people were in agreement. People’s every day choices were respected. For example people chose when to get up and where to spend their time.

Activities were arranged which were in line with people’s preferences, hobbies and interests. These took place both within the service and outside. Relatives were encouraged to get involved, for example some were involved in setting up a gardening club.

Care plans were informative and regularly reviewed and daily records were completed consistently. This helped staff stay up to date with any changes in people’s needs. In addition there were verbal handovers between shifts.

Staff meetings at all levels took place regularly. This was an opportunity to update staff on any changes in legislation or recommendations in respect of working practice. The registered manager and deputy manager had plans to develop the service and improve the environment. For example they were keen to start recording people’s personal histories to help staff meaningfully engage with people. They were also planning sensory areas both in the building and in the garden. This demonstrated they were continually looking to improve the care provided.

Relatives told us communication had previously been poor but things had improved recently. No-one had made an official complaint but they were confident any concerns they had would be dealt with appropriately.

We identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 The actions we have asked the provider to take are detailed at the end of the full version of the report.

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

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

Is the service safe?

From the two outcomes we looked at during this inspection we found the service was not safe. The environment was in need of some attention. Internal windows were not clean. Items were stored inappropriately in corridors and bathrooms.

There was no effective process for assessing and monitoring the risks to people within the premises to identify issues that required attention within the home.

Staff were clear on the action they should take if they had any safeguarding concerns.

Is the service responsive?

From the two outcomes we looked at during the inspection the service was not responsive. People did not always experience care, treatment and support that met their needs. Care plans were not reviewed to reflect changes in people’s needs.

People were not always provided with the correct incontinence product and communally used toiletries were found in all bathrooms.

There was very little meaningful activity for people

You can see our judgement on the front page of this report.

Some of the people who used the service were not able to comment in detail about the service they receive due to their healthcare needs. We used our SOFI (Short Observational Framework for Inspection) tool for two to three hours in one of the home’s lounges. The SOFI tool allowed us to spend time watching what was happening and helped us record how people spent their time, the type of support they got and whether they had positive experiences. We also spoke to three relatives of people who lived at Trevern. We saw people’s privacy and dignity was respected and staff were seen to be helpful. We saw people engaged in individual activities and we saw people chatted with each other and with staff.

During our inspection, we found people’s views and experiences were taken into account in the way the service was provided and delivered in relation to their care, for example, we heard people refuse offers from staff and saw staff respected this.

People experienced care, treatment and support that met their needs and protected their rights, and people were protected because there were sufficient skilled, and experienced staff on duty.

Complaints were recorded and dealt with in a sensitive manner. Records were stored securely, and were accurate and legible.

Some of the people who used the service were not able to comment in detail about the service they receive due to their healthcare needs. We spoke to two people who told us that they were pleased to live at Trevern.

We used our SOFI (Short Observational Framework for Inspection) tool for approximately one hour in a lounge/dining area. The SOFI tool allowed us to spend time watching what was going on and helped us record how people spent their time, the type of support they got and whether they had positive experiences. We saw people’s privacy and dignity was respected and staff were helpful. We did not see people engaged in activities, although we saw people chatted with each other and with staff.

During our inspection, we found people’s privacy, dignity and independence were respected and people’s views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

People experienced care, treatment and support that met their needs and protected their rights, and people were protected against abuse and the risks associated with medicines, because the staff had had training and there were appropriate policies and procedures in place.

We found staff received appropriate professional development and supervision.

We spoke with some people who were able to talk to us about the service and about how they make choices in the care they receive. They told us that they have the opportunity to express preferences and make choices. There is a stable team of care workers that work hard to meet the needs of the people that live there. People said they were happy with the care provided and 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”.