Trewiston Lodge is a care home which offers care and support for up to 32 predominantly older people. At the time of the inspection there were 32 people living at the service. Some of these people were living with dementia. The service occupies a detached house over two floors.

This unannounced comprehensive inspection took place on 5 June 2018. The last inspection took place on 15 March 2016 when the service was meeting the legal requirements. The service was rated as Good at that time. Following this inspection the service continues to be rated as Good.

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.

We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect.

People told us, “Yes, I’m quite happy with it, if you don’t like something, you can always say so” and “The carers do involve me in the care plan and they go through it with me, any changes to my medication, the GP deals with it.”

Relatives told us, “Yes they (staff) are very good, second to none” and “It’s all 100% and they keep me up to date.”

The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes.

The premises were well maintained. The service was not registered for dementia care but there was some pictorial signage to support some people, who were living at the service, with early dementia who may require additional support with recognising their surroundings. The premises were regularly checked and maintained by the provider. Equipment and services used at Trewiston Lodge were regularly checked by competent people to ensure they were safe to use.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff. Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had no staff vacancies at the time of this inspection.

There were systems in place for the management and administration of medicines. It was clear that people had received their medicine as prescribed. Regular medicines audits were being carried out on specific areas of medicines administration and these were effectively identifying if any error occurred such as gaps in medicine administration records (MAR).

Meals were the subject of some concern to people at the service. We saw a meeting, requested by the people living at Trewiston Lodge, had been held to discuss the food provided. People were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy. However, we were told the food and drinks served were not always hot and not always to their liking. This issue was being addressed by the registered manager at a further meeting to be held with the kitchen staff.

People had access to some planned activities. An activity co-ordinator was not in post. Activities were provided by care staff. We were told staff workload pressures often led to the cancellation of planned activities. It was not clear how the activities were chosen. The activities provided were not always relevant and meaningful to everyone. People had been supported to go out in a minibus, supported by staff, to attend appointments, have coffee or visit local attractions. However, this had stopped recently. The registered manag

This unannounced comprehensive inspection took place on 15 March 2016.

The last inspection took place on 6 August 2014. The service was meeting the requirements of the regulations at that time.

The service is a care home which offers nursing care and support for up to 32 predominantly older people. At the time of the inspection there were 32 people living at the service. Some of these people were living with dementia. The service occupies a detached house over two floors.

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.

We walked around the service which was comfortable and personalised to reflect people’s individual tastes. People were treated with kindness, compassion and respect.

The service did not have a dedicated activities co-ordinator. Activities for people were provided by staff and external visiting entertainers. Staff told us they had access to resources such as skittles and card games. However, staff stated that they were only able to provide activities when time allowed them. They told us they had some time to sit and chat with people on an individual basis. There were regular bus trips out in to the community and film nights were held at the service. Religious services took place every two weeks. Many people were confined to bed due to their healthcare needs, or chose to stay in their rooms. It was not clear what meaningful activity was provided for these people. The service’s recent quality assurance survey showed 6% of people who responded felt that access to activities was poor.

We looked at how medicines were managed and administered. We found it was always possible to establish if people had received their medicines as prescribed. Regular medicines audits were being carried out to ensure any error would be identified.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. People living at the service were happy with the care and support they received from the staff.

Staff were supported by a system of induction training, supervision and appraisals. Staff knew how to recognise and report the signs of abuse. Staff received training relevant for their role and there were good opportunities for on-going training and support and development. More specialised training specific to the needs of people using the service was provided. For example, diabetes care and tissue viability (care of vulnerable skin). However, some staff required refresher training in areas such as fire safety, health and safety and safeguarding adults. We saw that some refresher training was planned for the near future. We were assured by the registered manager this would be addressed immediately.

Staff meetings were held regularly. These allowed staff to air any concerns or suggestions they had regarding the running of the service. Staff reported feeling they were listened to and issues were acted upon.

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

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs recorded. Where appropriate, relatives were included in the reviews.

The registered manager was supported by a deputy manager and a clinical lead. The service had senior care staff who were responsible for a range of audits and monitoring of the quality of the service provided.

The staff team was stable and only one member of staff had joined in the last year. The staff

We carried out this inspection to review the actions the provider had taken to address the concerns identified during our inspection 15 April 2014. At this inspection we looked at the two outcomes which had compliance actions against them, Care and Welfare and Records. Trewiston Lodge provided support to 30 people at the time of this inspection. The home also provided respite care to people on a short stay basis. This inspection was carried out by one inspector.

During our inspection of this service we considered our findings to answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

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

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

Is the service safe?

We judged the service to be safe on the day of our inspection.

Care plans were individualised and contained information that directed and informed staff to provide appropriate care and support. Care plans were reviewed regularly to take account of changes in people’s needs.

Documentation which recorded people’s food and fluid intake and repositioning were mostly completed accurately by care staff in accordance with the guidance in people’s care plans.

Medication records were mostly accurate and audited monthly by the lead nurse to ensure any gaps were noted and addressed with the appropriate member of staff. This ensured the service was continually monitoring and improving their medication records.

The medication refrigerator temperature was monitored although there were some gaps in these records. Daily temperature recording of the medication refrigerator ensured that any fault with the refrigerator would be noticed quickly and the safe storage of medicines inside would be ensured.

Is the service effective?

We judged the service to be effective on the day of our inspection.

During our inspection we observed staff caring for people. It was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people’s needs.

People we spoke with told us they had their needs met at Trewiston Lodge and felt they could raise any issues with the staff at any time and felt they would be listened to.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

People’s health and care needs were reviewed regularly to take account of any changes which may have occurred.

Staff told us they felt they all worked well as a team and were happy working at the home.

Is the service caring?

We judged the service to be caring on the day of our inspection.

Our observations of the care provided, discussions with staff and records we looked at enabled us to conclude that individual wishes regarding people’s care and support were taken into account and respected.

People we spoke with told us they felt well cared for. Visitors we spoke with told us they felt their family member was well cared for and were happy living at the service.

From discussion with the staff, it was clear they understood the people’s needs well. We were told the registered manager did their best to ensure the people were well cared for, and promoted people to have suitable opportunities and choices.

People’s preferences, interests, aspirations and different needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

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

From discussion with the staff, and from inspection of records we judged there were suitable links with local health services. Records showed there was appropriate contact with medical professionals.

We saw people who lived at the home were supported to make choices such as where they wanted to spend time and what they would like to eat.

We saw evidence of people’s end of life wishes in the care records. When people had been assessed as not able to make specific decisions for themselves, we saw evidence of best interest decision meetings in the care files.

People’s care needs were regularly reviewed, however, this was not always done with the involvement of the person or their representative.

Is the service well-led?

We judged the service to be well-led on the day of our inspection.

The registered manager told us the home was constantly striving to improve the service it provided. The concerns raised at the last inspection had been largely addressed by the registered manager and the staff. We saw evidence of this since our last inspection. For example, medication chart audits had taken place monthly since our last inspection, to ensure any gaps in the records were noted and addressed with the member of staff.

We saw food and fluid intake and repositioning charts were mostly accurate and in accordance with the guidance in the person’s care plan. The registered manager told us there were plans for these charts to be regularly audited by senior care staff in the future, to ensure they were accurately completed by care staff.

Trewiston Lodge accessed regular support from the district nursing team and GP’s from the local GP practices. This ensured people received appropriate care in a timely way.

We considered our inspection findings to answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them ad looking at records.

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

Is the service safe?

We saw people were treated with respect and dignity by the staff.

People were cared for in an environment that was safe, clean and hygienic.

Care plans were individualised, but did not always contain accurate information that directed and informed staff to provide appropriate care and support.

Newly appointed staff received an induction prior to starting work, which included a period of shadowing more experienced staff.

Mandatory training was mostly up to date and staff received further training specific to the needs of the people they supported.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints and concerns. This reduced the risks to people and helped to continually improve the service.

CQC monitors the operation of the Deprivation of Liberty Safeguarding which applies in care homes. While no applications have needed to be submitted, appropriate policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

We reviewed the medication administration records (MAR). These records showed that people received their prescribed medication at the appropriate time. Procedures for the administration of medicines were robust.

Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Accurate records in respect of people who lived at Trewiston Lodge were not always maintained.

Is the service effective?

During our inspection we observed staff caring for people. It was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people’s needs.

We spoke with five people who lived at the home, comments included “I am happy here it’s nice enough” and “staff come quickly when I call”.

We spoke with the four family members of people who lived at Trewiston Lodge, comments included “we are very happy with the care” and “I have no complaints at all, the staff are lovely and they seem to care for X very well”.

People’s health and care needs were initially assessed with them. However, people who used the service, and their representatives, were not always involved in their care plan reviews. We did not see evidence that people, or their representatives, had signed care plan reviews to show they had read and agreed to the content of the care plan.

Risk assessments were carried out to ensure people were protected from the risk of harm and guided staff on any action needed to minimise risk.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service caring?

People were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people.

People who used the service told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us “I like to get up early, it’s no problem”.

People’s preferences, interests and different needs had been recorded.

We saw people were given choices as to where and when they had their meals, and what they chose to eat. We saw people choosing to eat their meals in their rooms; others ate in the communal dining area. People we spoke with told us “lovely food” and “we can change our minds about what we have (meals) if we want”.

One person told us “I stay in bed and like to sit like this, they (staff) regularly ask me to move, but I like to stay like this and they respect that, my choice”.

Is the service responsive?

We saw some activities took place in the lounge area. Many people who lived at Trewiston Lodge had complex health needs and were either not able, or chose not to join in group activities. It was not clear from the records what occupation was provided for these people.

We saw the complaints policy held by the home clearly set out the procedure for people to raise any concerns they may have.

Trewiston lodge regularly assessed people who lived at the home to ensure there were sufficient numbers of staff available to meet their needs.

We spoke with four care staff and two nurses, comments included “it’s good here we are a good team, we get time with the clinical lead and have meetings so we can have our views heard”

People using the service and their relatives had completed a satisfaction survey. Where shortfalls or concerns were raised we were told these were addressed.

Is the service well-led?

Trewiston Lodge had regular support from the district nursing team and GP’s from the local GP practices. This ensured people received appropriate care in a timely way.

We saw the minutes of regular meetings held with care staff and nurses. This showed the management consulted with staff regularly to gain their views and experiences and improve support for people who lived at the service.

Staff told us they were offered relevant and useful training on a regular basis. Staff also told us they felt supported by the registered manager and could approach them at any time if they had a concern.

Staff received supervision and appraisals.

People confirmed they had completed a customer satisfaction survey. We were told as a result of the survey changes had been made.

Regular audits were carried out to ensure the home was operating effectively and safely. Where these identified need for action this was followed up.

Staff told us they were clear about their roles and responsibilities. They said the management had consulted with them and their views had been taken in to consideration.

We carried out this inspection to review outstanding compliance actions from our last inspection in June 2013. We had concerns in three areas. Previously we found the planning and delivery of care did not ensure the welfare and safety of the service user, the provider had not taken reasonable steps to ensure staff were able to recognise the possibility of abuse, and there was not an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who lived at Trewiston Lodge.

Trewiston Lodge provided residential and nursing care for 29 people at the time of this inspection.

We saw that people’s privacy and dignity was respected, and people experienced care, treatment and support that met their needs and protected their rights.

We found staff had received training and were knowledgeable about the process for reporting safeguarding concerns.

We saw Trewiston Lodge had systems in place to monitor care provision, and were auditing the quality of processes used at the home.

Some people living at Trewiston Lodge were not able to tell us verbally about their experiences due to their healthcare needs. Therefore we used a number of different methods to help us to understand the experiences of people, including looking at records and observing care being delivered. People told us they had “lovely staff” and they were happy with their care.

We looked at care documentation for five people and saw evidence of individualised care planning that showed people’s preferences, likes and dislikes. People told us that they felt involved in their care and could spend their day as they wished.

Whilst people looked well cared for, we found people did not always have their care needs met due to a lack of guidance for staff, recording, monitoring and review of care plans.

People were not consistently protected from the risk of abuse because the provider had not taken reasonable steps to prevent it from happening.

People were not protected from the risks associated with medication administration because the provider did not have the appropriate arrangements in place to manage medicines.

Trewiston Lodge did not have an effective system to assess and monitor the quality of service that people received.

Some people were not able to verbally tell us about their experiences. Therefore we used a number of different methods to help us to understand the experiences of people, including looking at records and observing care being delivered. People said they were happy at the service and that they were well cared for.

People we spoke with said they understood their care plans and that staff had discussed their needs with them and explained things in detail. One person said they felt very involved in the decision making process and that they had contributed to the way their care was delivered.

Whilst people looked well cared for, we did find that they were not always kept safe because the management of medication was not robust. Despite this, people said they received their medication when they needed it. One person said, “The staff deal with my medication, I get it on time as far as I know.” Another person told us they needed regular tablets for pain relief and that the staff made sure these were given on time to help with that.

Staff told us that they felt well supported by the manager and owner and that they thought the home provided a good service.

People said they knew how to make a complaint if they needed to do so. They also told us that they would not hesitate to speak to the manager or owner if they had a problem.