Archived: Trefula House

Trefula is a care home that provides personal and nursing care for up to 44 people, all who are living with dementia, and / or have other mental health issues. At the time of the inspection 41 people lived at the service. All of the people lived there permanently. The service primarily caters for people aged 65 and over, although at the time of the inspection some younger people were accommodated. The service was divided into two restricted units; ‘St Mawes’ / ‘Restormel’, and ‘Pendennis’ / ‘Carn Brea’. Pendennis / Carn Brea provided a higher emphasis on general nursing care. Both accommodated people with dementia and/or other mental health care needs.

People’s experience of using this service:

¿ Steps taken to minimise the risk of unwelcome visitors going into other people’s bedrooms were not always effective. This caused some people anxiety. Suitable steps were not taken to safeguard people.

¿ Risk assessment processes were not always safe for example, in the case of specific individual’s: regard to the use of bedrails, emergency evacuation plans in the case of a fire; pressure sore prevention.

¿The lack of suitable recruitment checks put people at risk from staff who were not fit to work with vulnerable people. Staffing levels and deployment was not always sufficient to meet people’s needs.

¿ Medicines were not always managed safely. The management of external preparations, such as creams and lotions, was not effective. The service did not have an effective audit system. People’s medicines such as skin patches were not always managed safely. The gaps between medicine rounds were often not satisfactory which could result in medicines being given too closely together.

¿ Infection control procedures were not always effective. For example, we had concerns about the storage of some infection control products, and the cleanliness of some areas within the service.

¿ Assessment processes, before people came to live at the service, were not always satisfactory, and led to the service agreeing to admit some people who were not suitable to live there.

¿ Staff induction, training, supervision and appraisal systems were not always satisfactory. This meant staff were not always equipped with the right skills, knowledge and support.

¿ People did not always receive the correct support with eating and drinking. For example, this put some people at risk of choking. Records kept were not always sufficient.

¿ Health care records were not always comprehensive and did not detail what treatment people had received, or when this was next required.

¿ People’s rights were not always maintained in line with the Mental Capacity Act 2005. For example, when conditions were applied to Deprivation of Liberty Safeguard agreements, there was not always sufficient evidence these were being met. Staff training and knowledge about the Mental Capacity Act 2005 was not always effective.

¿ People did not always have access to a call point to summon staff in emergency

¿ People did not always have regular opportunity to have a bath or a shower.

¿ Care planning and guidance for staff to provide good quality care was not always satisfactory. Care plans were not always reviewed regularly and therefore were inaccurate.

¿ There were not sufficient planned activities available to people on a regular basis.

¿ End of Life care planning was not satisfactory and did not give staff guidance about people’s wishes and needs.

¿ Management was not effective, and had not provided person centred high quality care.

¿ Governance arrangements were not satisfactory. For example, there were inadequate audit and quality assurance arrangements to assess service quality, and bring about improvements when required.

¿ People said they liked the food, were provided with a choice, and were offered regular drinks.

¿ People said they liked the staff, and staff were kind and respectful.

¿ Staff said training was good, and they had received comprehensive training in relevant areas such as moving and handling.

¿People and their representatives said they felt confident if they made a complaint it would be dealt with quickly.

Rating at last inspection: Rating at last inspection: ‘Requires improvement.’ (published on 11 January 2019.)

Rated ‘Requires Improvement’ in the two last inspections. At this inspection we found the service had deteriorated and is rated as inadequate overall.

Following the last inspection, asked the provider to complete an action plan to show what they would do and by when to make improvements to the service. We also met with the provider to discuss our concerns and receive assurance about planned improvements.

Why we inspected: We completed this inspection to check whether suitable action had been taken, following the enforcement action we took following the last inspection. We also received concerns from the local authority and the clinical commissioning group about the operation of the service. Concerns were also received from whistleblowers and members of the public. Subsequently a full comprehensive inspection was completed

Enforcement During the inspection we identified 6 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in regard of person centred care, consent to treatment, safe care and treatment, good governance, staffing, and fit and proper persons employed. Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

People were at risk from harm because the provider’s actions did not sufficiently address the ongoing failings. There has been ongoing evidence of the provider to sustain full compliance since 2016. Our findings do not provide us with confidence in the provider’s ability to bring about lasting compliance with the requirements of the regulations.

Follow up: During the safeguarding process the service is being monitored through a combination of visits by health and social care staff, as well as multi-disciplinary safeguarding strategy meetings.

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Trefula is a ‘care home’. 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. Trefula accommodates 44 people across two separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. In the other unit people may also have dementia, but there was also a greater emphasis on nursing care for people who were physically unwell.

The service had 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.

At the last inspection we had some concerns about personal care and skin care for some people. As part of this inspection we liaised with the community tissue viability team. They said staff liaised well with them and they had no concerns about pressure relief and wound care. We assessed the care of people at risk of pressure damage. We had no concerns about care delivered by staff. Overall records demonstrated suitable care and treatment for people with these needs although there was still some inconsistency how these records were kept in respect of this aspect of care.

At the last inspection we also had some concerns about whether people’s rights to consent to their care, and measures taken if people could not, were suitably managed within the boundaries of the Mental Capacity Act 2005. At this inspection we found people had a fully completed mental capacity assessment, and where necessary applications had been submitted to the local authority where the registered persons’ had assessed a person lacked capacity. However, we did have concerns there was not suitable information to readily demonstrate any conditions of any authorisations to deprive someone of their liberty were being acted upon. Also, we had concerns that nursing staff within the care home were signing treatment escalation plans, which served to say people should not be resuscitated should this be medically necessary, and the person lacked capacity. These should have been signed by external professionals. Some people had behaviour which challenged the service. As a result these people sometimes required staff to use physical behaviour techniques to prevent them from harming themselves or others. Where this was necessary guidance, about individuals needing this support, was limited. For example, there was a photocopy of what physical holds should be used but this was generic and not person centred.

People, and their representatives told us they were safe. For example, comments we received included: “There’s just a nice safe feeling about the home.” Suitable policies and procedures were in place to ensure people were protected if there were any allegations of abuse. Staff had received safeguarding training. Due to concerns about how two people were looked after we did put in two safeguarding referrals following this inspection.

The service had suitable policies and procedures about risk assessment to monitor any risks to people (such as poor nutrition and hydration, and falls) or others (such as aggression). Risk assessments were satisfactory, but the process of review was not always completed.

Equipment (such as hoists and wheelchairs) were suitably maintained. Health and safety checks (for example checking fire precautions, and electrical checks) were routinely completed appropriately.

Staffing levels were adequate. Concerns were expressed to us about staff sickness levels particularly at the weekends which resulted in staff shortages if agency staff could not be provided. Although there was usually a registered mental nurse on duty, during part of each day, this was not always the case. People who used the service sometimes had a high level of need due to their mental health needs. We were assured by the registered manager suitable processes were in place to monitor staff sickness and take appropriate action to minimise excessive sickness levels. We have made a recommendation about staffing levels.

Staff induction processes were in place. However, we did have some concerns about the brevity of formal induction in place. Staff undertook a day’s formal induction with a trainer. This covered an extensive number of areas. We were concerned if this was the only formal discussion which took place it may result in staff being overloaded, and not taking in appropriately required information. The registered manager said staff completed the Care Certificate if they previously did not have experience in the care sector. Staff told us they subsequently completed shifts with experienced staff. One member of staff we spoke to said this was over a two week period. There was no documentary evidence, in personnel files, to state when staff did undertake shadow shifts.

Staff were appropriately trained to carry out their jobs although there were some gaps in the receipt of some training received by some staff. There were limited records of staff supervision for staff members although there were always more senior staff on duty who care staff could approach if they needed help and advice.

We had concerns about some aspects of the medicines’ system. For example, we found there was many instances where medicines had been signed for but remained in blister packs. No reason was provided on medicine administration records as to why these medicines had not been given. There were some medicines, within medicine cabinets, where there was excessive stock, and had not been returned to the pharmacist. There were concerns about administration records not being completed for the administration of creams and lotions.

The service was generally clean and hygienic, and staff received training about infection control. However, we did have some concerns about how the service minimised the risks of risk of infection. For example, how some rubbish and contaminated items were stored.

There were suitable pre admission assessment procedures, to check if people’s needs could be met. Everyone had a care plan and these were regularly reviewed. We witnessed an assessment being completed. This was completed in one of the lounges, with private and confidential information being discussed, where other staff, and people who used the service, were present.

People’s care plans were not always up to date, and information within them was not always reflective of people’s current needs. Care plan review was inconsistent. Some care plans were being reviewed on a monthly basis, whereas other care plans had either not been reviewed at all, or had not been reviewed for several months. Some people were considered to be at the end of their lives. The registered manager provided us of a list of people who were designated as requiring ‘End of Life’ care. This was not accurate and we found more people requiring end of life care. None of these people had a specific care plan outlining their specific needs or wishes about this stage of their lives. These people’s care plans were also not reflective of their current needs.

People were happy with the food. The meal times we observed were pleasant and unrushed occasions. People had a choice of meals. Someone told us: “There is a good choice and you can always have something else if you let them know,” and “The food is always lovely and hot.” Some concerns were expressed about the presentation of soft and pureed diets. For example, some of the catering staff prepared these foods well whereas others presentation skills were less developed. There were some concerns that food and fluid charts were not being maintained correctly which meant that management were not able to satisfactorily monitor the food and drink consumption of more vulnerable people at the service.

There were good links with external professionals. People could access relevant external professionals such as GP’s, community matrons, chiropodists, dentists and community psychiatric nurses. External professionals were positive about the care provided at the service. However, there were limited records in people’s care plans about when people had last seen some medical professionals such as a dentist or an optician.

The building was suitable for the people who lived there. Most people could walk around the service, and had access to a garden having to ask staff to accompany them or access different areas. The building was satisfactorily maintained, warm and comfortable. However, some of the areas were looking a bit worn and in need of redecoration and renovation. We have made a recommendation about the suitability of the premises.

People, their relatives and external professionals thought the service was caring. Relatives said, “Some staff go above and beyond,” “They are absolutely wonderful….there is a community or a family atmosphere,” Care practice we observed was to a good standard. Staff did not rush people and were patient. People could see visitors when they wanted, and visitors said they felt welcome.

Some acti

Trefula is a ‘care home’. 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. Trefula accommodates 44 people across two separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia.

The service had 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.

We had some concerns about personal care and skin care for some people. We concluded the registered persons should have liaised more promptly with tissue viability nurses when there were concerns about the effectiveness of pressure relief, and when people’s skin conditions failed to improve as planned.

We also had some concerns about whether people’s rights to consent to their care, and measures taken if people could not, were suitably managed within the boundaries of the Mental Capacity Act 2005. The majority of people did not have capacity. However not everybody had a fully completed mental capacity assessment. Due to some people’s behaviour, approved techniques to assist people to minimise any difficult behaviours needed to be used. However guidance, about individuals needing this support, was limited. There was no evidence that the multi-disciplinary team had made decisions, through a best interest process, about the techniques used.

People were safe. For example, one person told us: “Staff make me feel safe. They are nearby if I need them.” Suitable policies and procedures were in place to ensure people were protected if there was any allegations of abuse. Staff had received safeguarding training.

The service had suitable policies and procedures about risk assessment to monitor any risks to people (such as poor nutrition and hydration, and falls) or others (such as aggression).

Equipment (such as hoists and wheelchairs) were suitably maintained. Health and safety checks (for example checking fire precautions, and electrical checks) were routinely completed appropriately.

Staffing levels were satisfactory. Call bells were answered promptly on the day of our inspection and an external professionals commented: “The staffing levels seem appropriate and carers appear caring and supportive.” Satisfactory staff induction processes were in place. Staff were generally appropriately trained to carry out their jobs, although we did think training about pressure ulcer prevention, and wound care could be improved. Staff recruitment checks were satisfactory. The staff supervision and appraisal system needed to be improved so staff received more frequent meetings with their supervisor. However, staff told us they felt supported by management.

The medicines system was generally satisfactory, although the management of creams, eye and ear ointments needed some improvement. We have made a recommendation in relation to this.

The service was clean and hygienic. Staff received training about infection control and understood the need to wear protective clothing as necessary. There were suitable pre admission assessment procedures, to check if people’s needs could be met. Every one had a care plan and these were regularly reviewed.

People were happy with the food. People had a choice of meals. Someone told us: “The food is always hot and tasty. “Where people needed to have what they ate and drank monitored, records could be improved.

Generally there were good links with external professionals. People could access relevant external professionals such as GP’s, community matrons, chiropodists, dentists and community psychiatric nurses. External professionals were positive about the care provided at the service. Comments included: “They deal with some very complex people, but they do a good job. They are always looking to make improvements.”

The building was suitable for the people who lived there. Most people could walk around the home, and had access to a garden having to ask staff to accompany them or access different areas. The building was suitably maintained, warm and comfortable.

People, their relatives and external professionals thought the service was caring. Comments received included: “All staff are kindly, patient and caring,” and “People flourish at Trefula.” The majority of care practice we observed was to a good standard. Staff did not rush people and were patient. People could see visitors when they wanted, and visitors said they felt welcome.

There was a range of activities on offer. For example crafts, arts and various entertainers. A full time and a part time activities organiser were employed.

The service had a complaints procedure. Records were kept of any complaints made. People and their relatives who we spoke with said they could talk to staff if they had any concerns. The people we spoke with said they felt if they had any concerns and complaints these would be appropriately responded to.

The service had a suitable approach to supporting people with end of life care. The registered manager said there were good links with GP’s to ensure people received suitable medical care during this period of their lives.

Management were viewed positively. Comments received included that management were: “Approachable,” and “Very good.” There was a clear management structure and always senior staff on duty to ensure shifts were well managed and staff could seek support.

The service had suitable approaches to ensure the service was maintained to a satisfactory standard. There were a range of audit systems in place for example to check care planning, training, and standards of care were appropriate. An annual survey was completed. The published results were positive. However the management of the service had not picked up the concerns we found in this report and this has resulted in a breach of regulations.

You can see what action we told the provider to take at the back of the full version of the report.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 inspected Trefula on 25, 26 and 27 July 2016. The inspection was unannounced. The service was last inspected in July 2015 when it was found to not be meeting the requirements of the regulations. At that inspection we identified two breaches of the legal requirements. These breaches related to how medicines were managed and the delivery of training. We subsequently issued two requirements and told the provider to take action to address the two breaches of the regulations. The provider sent the Care Quality Commission an action plan following the publication of the report. We carried out this inspection to check to see if the service had made the required improvements identified. We also reinspected all other areas as the service received a ‘requires improvement’ rating at the last inspection. We were satisfied suitable action had been completed regarding the requirements we made.

People told us they felt safe at the service and with the staff who supported them. People told us, “Yes (I am safe), I cannot say there is anything to worry about,” and a relative told us “We feel that the service is safe.”

People told us they received their medicines on time. Medicines administration records were kept appropriately and medicines were stored and managed to a good standard.

Staff had been suitably trained to recognise potential signs of abuse. Staff told us they would be confident to report concerns to management, and thought management would deal with any issues appropriately.

Staff training was delivered to a good standard, and staff received updates about important skills such as moving and handling, and health and safety at regular intervals. Staff also received training about the needs of people with dementia. Nursing staff had received training in respect of their professional development..

Recruitment processes were satisfactory as pre-employment checks had been completed to help ensure people’s safety. This included written references and an enhanced Disclosure and Barring Service check, which helped find out if a person was suitable to work with vulnerable adults. Staff received a comprehensive induction.

People had access to medical professionals such as a general practitioner, dentist, chiropodist and an optician. People said they received enough support from these professionals. However, examples of when people had attended dental appointments were variable. The registered manager said she would look into this, as the dentist did see people regularly.

There were enough staff on duty and people said they received timely support from staff when it was needed. People said call bells were answered appropriately and we observed staff being attentive to people’s needs.

The service had a programme of organised activities. An activity organiser was employed, although at the time of the inspection she was on maternity leave. Activities currently provided included group table top games such as dominos, singing and baking. External entertainers such as musicians and singers visited on a regular basis.

Care files contained information such as a care plan and these were regularly reviewed. The service had appropriate systems in place to assess people’s capacity in line with legislation and guidance, for example using the Mental Capacity Act (2005).

People were happy with their meals. Everyone said they always had enough to eat and drink. Comments received about the meals included “It is nice,” and “There is always enough to eat and drink.” People said they had a choice of meals available. People received enough support when they needed help with eating or drinking.

People we spoke with said if they had any concerns or complaints they would feel confident discussing these with staff members or management, or they would ask their relative to resolve the problem. They were sure the correct action would be taken if they made a complaint.

People felt the service was well managed. We were told management were: “Approachable and caring,” and that they “Listen.” There were satisfactory systems in place to monitor the quality of the service.

Trefula House sent us the training records, supervision records, details of the induction process for new staff and copies of rotas to show when new staff had been shadowing experienced staff.

We found Trefula House staff had undergone training in a variety of areas since our last inspection. New staff were provided with induction upon joining the home. Most staff had recieved supervision, some had not recieved any supervision according to the records.

Accommodation was decorated, furnished and maintained to a satisfactory standard, although some areas were in need of upgrading. When we inspected the home was clean and odour free. A satisfactory system was in place regarding staff recruitment checks. Staff training needed to be improved. Staffing levels were judged as satisfactory although some people commented these could be improved. Overall quality assurance systems were satisfactory.

Some of the people that lived at Trefula House were unable to tell us about their experiences. We did speak to people who lived at Trefula House, and a visiting healthcare professional. All the comments we received from people who lived at Trefula House were positive.

We spoke to two relatives of people that lived at Trefula House. Comments from these people included '[staff are] really brilliant', 'the staff are like a group of friends' and 'I can't think of anything they could do better'.

A GP told us that they thought people had a 'reasonable quality of care' and that staff made 'good judgements as to when to call other health professionals'. The GP confirmed they had no concerns about care provision at Trefula House. A representative of the local Health Authority confirmed that there were no current concerns about the home.