Tryfan House

Updated 16 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors, a medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Tryfan House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. [Care home name] is a care home [with/without] nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Before the inspection, we reviewed all the information we held about the service including information about important events which the service is required to tell us about by law. We requested feedback from other stakeholders. These included the local authority safeguarding team, commissioning teams, infection and prevention control team and Healthwatch Leeds. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We spoke with 5 relatives about their experience of the care provided. We observed care in the communal areas to help us understand the experience of people. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We gathered information from several members of staff including the registered manager, unit manager, nurse, senior carers, care staff and activity coordinator.

We reviewed a range of records. This included 3 people's care plans, risk assessments and associated information, and other records of care to follow up on specific issues. We also reviewed multiple medication records. We looked at 3 staff files in relation to recruitment, training, supervision and appraisals. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 16 June 2023

About the service

Tryfan house is a care home that can accommodate up to 30 people who require support with nursing or personal care needs, some of whom were living with dementia. At the time of our inspection, 22 people were living at the service.

People’s experience of using this service and what we found

Relatives told us their loved ones received safe care and, in our observations, we saw people were relaxed and being supported by staff who knew them well.

Most risks to people’s care were assessed and measures put in place to manage these, such as risk of falls or weight loss. However, we saw examples of documentation not always being detailed or completed when people required additional support due to displaying distressed behaviour or evidence of monitoring following an incident or physical restraint. Although there was ongoing cleaning happening, we found examples of some areas at the home or objects used by people not being clean. Most areas of recruitment were managed safely but we found examples of additional improvements required. Medicines were well managed. Staffing levels were safe.

The environment was not always dementia friendly or homely; there was an ongoing programme of redecoration at the home. Staff asked consent before supporting people with care tasks. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported to maintain a balanced diet and had access to the relevant healthcare professionals to meet their needs.

The service was located on the same grounds as another 5 care homes owed by the same provider and we saw care documentation related to people living at Tryfan house or any of the other care homes could be accessed by any staff working in those services. This posed a risk to people’s confidentiality. People were supported by staff that were caring, compassionate and respectful. People's independence was promoted.

Most care plans were centred around people’s needs and preferences however, we also found inconsistencies and areas that required additional detail. People were offered a regular programme of activities tailored to their needs. People who required end of life care received the care they needed. The service had not received any complaints, but the necessary policies and procedures were in place to manage these.

Some areas of the management of the home needed improvement. Quality assurance systems were in place and happening regularly, however these had not always been effective in identifying or addressing in a timely way the issues found at this inspection. We have made a recommendation in relation to ensuring quality assurance processes are effective to ensure adequate management’s oversight. We saw evidence of good partnership work with other professionals, to meet the needs of people using the service. There were plans to continue developing the service. The management team supported this inspection, were receptive to findings and told us the actions they would take to address issues identified.

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

Rating at last inspection

This service was registered with us on 14 February 2023 and this is the first inspection.

The last rating for the service at the previous premises was Inadequate, published on 10 June 2022.

Why we inspected

This was a planned inspection.

Enforcement and Recommendations

We made a recommendation in relation to good governance.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.