Trecarrel Care Home

Trecarrel Care Home is a residential care home providing personal care to up to 44 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 40 people using the service.

Trecarrel is part of the Cornwallis Care Services Ltd group of care homes based in Cornwall.

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

The provider had effective safeguarding systems in place and staff knew what actions to take to help ensure people were protected from harm or abuse.

People received their medicines as prescribed. Regular checks and audits of the medicines management system were effective.

The recruitment processes were thorough. New staff confirmed they received support and induction before working alone. There were sufficient staff to meet people’s needs. Most staff were happy and many had worked at Trecarrel Care Home for several years.

The service was clean and decorated to a good standard. There were no malodours.

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.

Staff worked within the principles of the MCA and sought people's consent before providing personal care and assistance. Care plans guided staff to help build independence wherever possible.

Identified risks were assessed and monitored. Care plans contained guidance and direction for staff on how to meet people’s needs.

People’s views and experiences of the food provided at Trecarrel had been sought. A recent survey received mixed responses. Food looked appetising and there were staff available to support people where needed. However, some staff did not always support some people appropriately with their meal. We have made a recommendation about this in the effective section of this report.

The manager, deputy manager and the provider had effective oversight of the service. There was a robust audit programme in place to help identify any areas of the service that may require improvement.

People, staff and relatives were being asked for their views and experiences by the manager. Staff meetings were held to share information and seek their views. The manager was supporting some staff with an issue of disharmony in the team.

The manager understood their responsibilities under the duty of candour. Relatives were kept informed of any changes in people’s needs or incidents that occurred.

The management team and staff worked closely with local health and social care professionals to meet people’s needs.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was requires improvement (30 November 2022). We carried out an unannounced inspection of this service on 14 October 2022. A breach of legal requirements was found in relation to inconsistent leadership.

Why we inspected

We undertook this focused inspection to check if the provider had made improvements and if they were now meeting the legal requirements. This report only covers our findings in relation to the key questions safe, effective and well-led.

We had also received safeguarding concerns from a member of the public which were being investigated by the manager at the time of this inspection.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Trecarrel Care Home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

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

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

Many people living at Trecarrel were unable to fully express their views of living there due to their cognitive impairment. However, we observed how people spent their time and how staff interacted with them. We found people were relaxed and comfortable with staff and had no hesitation in asking for help from them. Staff responded quickly when people requested assistance. Staff were caring and spent time chatting with people. Some people were able to comment, “Permanent staff are brilliant, including the night staff” and “I still love this place. I love the staff; they will do anything for you.”

Prior to the inspection we had received some concerns about the security of the premises. Security arrangements had been reviewed and some alterations to the premises had been made to strengthen the security of the home.

Prior to the inspection we had received anonymous concerns regarding the number of changes of manager at the service and how this impacted on people’s care, and the oversight of the service. At the time of the inspection, there was no manager registered with the Care Quality Commission (CQC). The provider acknowledged that this had impacted on the service and a new manager had been recruited. Following the inspection, the manager was no longer in post and a new recruitment campaign was in process.

The provider and the service governance team had, prior to the inspection, identified issues in respect of lack of consistent management and oversight of the service. The provider had identified issues with medicines systems due to the number of errors. They had put in place action plans to address these issues and shared them with us. However, this was still in the early days of implementation and further time to embed this was needed.

People expressed mixed views about the food and drinks available. We have made a recommendation about this that the provider engages with people in a review of the quality of food provision.

There were staff vacancies at the time of this inspection. Regular in-house bank staff were being used to cover these absences whilst a recruitment campaign was on going. Duty rotas confirmed that there was a mix of permanent and in house bank staff on duty so that people were supported by members of staff that were familiar to them on each shift.

People had access to call bells to alert staff if they required any assistance. We saw people received care and support in a timely manner and calls bells were quickly answered.

People were complimentary about the staff. Comments included “Staff know what they’re doing. They have lots of training. They support me with my care, bathing, getting around talking to me, they are gentle and explain things” and “Staff and domestic support staff are very good and dedicated, I just hope they stay.”

Staff supported people to have choice and control in their everyday lives. Their ability to do this had been impacted by staffing shortages which meant people were not always able to have their care needs met at a time that suited them.

All necessary recruitments checks had been completed. New staff completed an induction.

The provider had effective safeguarding systems in place and core staff had a good understanding of what to do to help ensure people were protected from the risk of harm or abuse.

Information about people's care needs, and any changes to those needs, were individualised, informative and shared effectively within the staff team. Risks were identified and staff had guidance to help them support people to reduce the risk of avoidable harm.

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 access healthcare services, core staff recognised changes in people's health, and sought professional advice appropriately. Health care professionals told us staff knew people well and contacted them if they had any concerns or queries and took on board any advice provided to ensure the person was cared for effectively.

Cleaning and infection control procedures had been updated in line with COVID-19 guidance to help protect people, visitors and staff from the risk of infection.

The premises were clean and reasonably well decorated. There was a plan to update and refurbish parts of the service, such as laying new carpets. Where faults and repairs to the premises were identified these were reported and actioned in a timely manner. Fire safety procedures and checks, as well as appropriate training for staff were in place.

We were assured that risks in relation to the COVID pandemic had been managed appropriately. Staff had access to appropriate PPE and hand washing facilities, which they used effectively and safely.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Last rating and update

The last rating for this service was good. (Report published on 8 October 2021).

Why we inspected

We were prompted to carry out this inspection due to concerns we received about staffing levels, management and impact on care of people. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have found one breach in relation to there being inconsistent leadership which had impacted on staff support and some aspects of the operational delivery of the service.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Trecarrel is a residential care home that provides care and accommodation for up to 44 older people, some of whom are living with dementia. At the time of the inspection there were 39 people living in the service.

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

Many people living at Trecarrel were unable to fully express their views of living there due to their cognitive impairment. However, we observed how people spent their time and how staff interacted with them. We found people were relaxed and comfortable with staff and had no hesitation in asking for help from them. Staff responded quickly when people requested assistance. Staff were caring and spent time chatting with people. Some people were able to comment, “Staff have been wonderful”, “They are perfect” and “Staff are all good.”

We also observed people having their lunch in one of the communal lounges. While the way staff interacted with people was caring and considerate, we found some staff, working in that lounge, were unaware when people needed support eating or cutting up their food. This resulted in a delay in people being helped until other staff were available to offer support. We have made a recommendation about staff training in relation to person-centred care.

People had access to call bells to alert staff if they required any assistance. We saw people received care and support in a timely manner and calls bells were quickly answered.

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.

Information about people's care needs, and any changes to those needs, were individualised, informative and shared effectively within the staff team. Risks were identified and staff had guidance to help them support people to reduce the risk of avoidable harm.

The premises were clean, reasonably well decorated and there were no malodours. Where faults and repairs to the premises were identified these were reported and actioned in a timely manner. Fire safety procedures and checks, as well as appropriate training for staff were in place. When faults were identified, for example if fire doors did not close, these were repaired in a timely manner.

Management assessed staffing levels based on the needs of the people living at the service. On the day of our visit the assessed number of care staff were on duty. The rotas for the rest of the week also had the correct number of staff booked to work. In the four weeks prior to the inspection there had been some occasions when staffing levels had been lower due to annual leave and staff sickness. The service had staff vacancies and recruitment to these posts was on-going.

Staff had received appropriate training and support to enable them to carry out their role safely and effectively. Some training and one-to-one supervision meetings had fallen behind, because they were postponed in August 2021 due to low staffing levels. However, training sessions and supervision meetings had been booked for September 2021.

We were assured that risks in relation to the COVID pandemic had been managed appropriately. Staff had access to appropriate PPE and hand washing facilities, which they used effectively and safely.

The medicines system was well organised, and staff received suitable training. People received their medicines on time.

There were effective assessing and auditing systems in place to monitor the quality of the service provided. The service sought the views of people, families, staff and other professionals and used feedback received to improve the quality of the service provided.

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

Rating at last inspection and update

The last rating for this service was good. (Report published on 7 January 2021).

Why we inspected

We received concerns in relation to staffing levels, fire safety measures, maintenance of the premises, medicines, infection control, staff training and how care was being provided. As a result, we carried out a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Trecarrel Care Home on our website at www.cqc.org.uk.

Follow up

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.

We found the following examples of good practice.

There had been an outbreak of Covid-19 at the service. Shortly after the start of the outbreak there was a change of management and the new manager had identified some areas for improvements in how the outbreak was being managed, at that time. These changes had been effectively implemented and included how the service was zoned, how staff were allocated, how staff took their breaks, correct mask wearing and the frequency of the cleaning of people’s bedrooms.

The service had been zoned into two areas to enable people who had Covid to be cared for in one area and people who were Covid free in the other. This also meant staff could work in separate teams dedicated to each zone, to help reduce the risk of cross infection. When the number of people infected increased and a large proportion of the staff team were unable to work, it had not been possible to maintain the separate Covid positive and Covid negative zones or have dedicated staff teams for each zone. However, people who remained free from infection were cared for by a small group of staff and were still separated in an area of one of the zones.

The procedure for staff and visitors to enter the premises was robust. Supplies of PPE and suitable hand sanitising facilities were available at the entrance to the service and throughout the building. The service had maintained good stocks of PPE throughout the pandemic. Appropriate waste bins were in place for the disposing of used PPE. There was signage at the entrance explaining the infection control measures in place and well as posters around the service to remind staff and visitors of the infection control procedures.

On arrival for their shift staff went to a designated room to wash and sanitise their hands and put on their uniforms before they entered the main area of the home. This helped to reduce the risk of infection because staff did not enter areas of the home, where people lived, until appropriate infection control measures were in place.

Staff breaks were staggered and only one staff member used the staff room at a time, due to the size and limited ventilation in the room. Staff also used the well-ventilated dining room for breaks when it was not being used by people living at the service.

Staff had completed infection prevention and control and Covid-19 training. Re-fresher training was completed as guidance changed and training was updated. Additional PPE, such as visors, had been provided for staff to use during the outbreak. Senior staff carried out observations of staff practice to check staff were competent in carrying out the correct infection control procedures. Staff were observed wearing and using the appropriate PPE.

All areas of the service were clean and uncluttered. Seating and tables had been spaced out in the shared areas to allow people to stay socially distanced. Effective cleaning routines had been put in place to ensure infection control risks were minimised and people were kept safe. Domestic staff hours had been increased at the start of the pandemic and further increased during the outbreak.

Staff had worked closely with external healthcare professionals to enable people to have access to the appropriate health care and equipment such as hospital beds and oxygen. There were daily calls with the GP where staff reported people’s daily observation results, such as oxygen levels. This meant, for people who were unwell with Covid, the right care could be provided in a timely manner.

Regular testing was carried out for staff and people who used the service. All visiting professionals were asked to either carry out a rapid test, and wait for the result before entering, or provide prove of a negative rapid test result carried out shortly before arrival.

Visiting had recently resumed, and relatives were tested in line with recent government guidance. The service had set up a visitor’s room close to a side entrance, so relatives could access the room without the need to walk through the main home.

The provider had reviewed the infection control policy in response to the pandemic. Specific Covid-19 policies had also been developed to provide guidance for staff about how to respond to the pandemic and the outbreak. These policies were kept under continuous review as changes to government guidance was published.

Further information is in the detailed findings below.

Trecarrel is a residential care home that provides care and accommodation for up to 44 older people, some of whom are living with dementia. At the time of the inspection there were 42 people living in the service.

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

There was a relaxed and friendly atmosphere at the service. People said they felt safe and well cared for. Relatives were complimentary about staff and the quality of care provided. Comments included, “[Person] is very happy living there and staff have been so kind”, “Staff are always patient and gentle", “Staff are caring and warm. They really care about [person] and understand their needs.”

Records of people's care were individualised and detailed their needs and preferences. Many people living at the home were identified as being at risk of falling and the service had robust systems in place to manage each person’s individual risks. Management and staff understood the balance between keeping people safe from the risk of harm and injury, due to falling, and enabling people to make informed choices about taking risks.

There were clear records to show, when assessed as needed, staff were monitoring specific health needs such as people’s weight, nutrition and hydration and skin care. Any changes in people’s health were escalated to the relevant professional and relatives were kept informed.

The medicines system was well organised, and staff received suitable training. People received their medicines on time.

Staff were recruited safely in sufficient numbers to ensure people’s needs were met. There was time for people to have social interaction and activity with staff. Staff knew how to keep people safe from harm. There was a stable staff team who knew people well and worked together to help ensure people received a good service.

The premises were clean, well maintained and there were no malodours. People had access to equipment where needed. Cleaning and infection control procedures had been updated in line with Covid-19 guidance to help protect people, visitors and staff from the risk of infection. During the summer months some families had met people in the garden and new arrangements were being set up for families to meet in a safe area of the home during the winter months.

There were effective assessing and auditing systems in place to monitor the quality of the service provided. People and their relatives were involved in decisions about people’s care and kept informed of any changes to the running of the service. People, their relatives and staff told us the management were approachable and listened when any concerns or ideas were raised.

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

Rating at last inspection and update

The last rating for this service was good. (Report published on 12 December 2019).

Why we inspected

The inspection was carried out to check if standards had been maintained in relation to the management and safety of the service. We carried out this focused inspection to review the key questions of Safe and Well-led only.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The overall rating for the service has remained good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Trecarrel Care Home on our website at www.cqc.org.uk.

Follow up

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.

Trecarrel provides accommodation with personal care for up 44 people. There were 38 predominantly older people using the service at the time of our inspection.

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

People received care and support that was individual to their needs and wishes. Care plans were regularly reviewed and updated and were an accurate reflection of people’s needs and wishes.

Medicine systems and processes were in place. People received their medicines safely and as prescribed.

Staff were recruited safely in sufficient numbers to ensure people’s needs were met. The service was fully staffed at the time of this inspection. Some staff absence cover was being provided by Cornwallis’s own bank of agency staff. Staff told us, "I have had three managers and this one is fantastic, she says she will do something, and it gets done” and " I am pleased to be at work now, it’s so much better."

There were systems and processes in place to monitor the Mental Capacity Act, and associated Deprivation of Liberty Safeguards assessments and records.

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. Any restrictive practices were regularly reviewed to ensure they remained the least restrictive option and were proportionate and necessary.

People told us, “When she (Manager) can, she comes and has a yarn with me" and “The manager is wonderful, very helpful and I'm happy with everything here."

Risk assessments provided staff with guidance and direction to provide person-centred care and support. Some equipment was not effectively addressing the identified risk, such as pressure mats. We have made a recommendation about this in the safe section.

Some people were living with specific long-term conditions. Not all care plans contained a specific section related to their condition. For example, separate diabetes or epilepsy care plans. The manager was aware of this and had begun to provide this information. They had also contacted the electronic care plan company to arrange for additional sections to be held in care plans for specific conditions. This would hold key information for staff in one place related to the person's specific needs.

People were provided with the equipment they had been assessed as needing to meet their needs. For example, pressure relieving mattresses. These were correctly set for the person using them.

Staff had received appropriate training and support to enable them to carry out their role safely.

There were activities provided for people both inside and outside in the garden and local community.

Audits were carried out regularly to monitor the service provided. Actions from these audits were being acted upon to further improve the service.

We observed many very kind and caring interactions between staff and people. Staff spent time chatting with people as they moved around the service.

People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.

Staff were well supported and felt valued. Comments included, “[The manager ] is our Celtic warrior, she does what she says she will and is always willing to roll up her sleeves and help us when needed, what more can you ask for?” and “We have never been so well managed she communicates with us all the time, she has high standards and expects us to have them too.”

Complaints and their responses were recorded. The manager told us there were no on-going complaints at the time of this inspection.

Compliments received included, “Personally I am very pleased with care and attention of Mum. The staff are always very considerate, and the overall condition of the home is clean and tidy” and “Trecarrel Care Home is efficient and organised with a calm warm, friendly atmosphere. Staffing levels are very good and staff are very kind and caring to both residents and visitors. Needs have been anticipated and met, which has helped to make a very difficult time a lot easier. There have been no concerns, only reassurance and relief.”

The manager had only been post for six months prior to this inspection. They had worked hard to bring about the improvements required at Trecarrel. They were open, visible and committed to further improving the service.

Healthcare professionals were positive about the improvements noticed at the service. One told us "I think [Manager] is outstanding. She is amazing, a strong leader that checks things are followed through. She is open and takes comments on board and acts on them."

Relatives told us, “The manager is tops, somebody you can speak to" and “If anybody said to me what do you think of Trecarrel, I'd say, its brilliant.”

Rating at last inspection and update:

At the last comprehensive inspection, the service was rated as inadequate (report published 18 June 2019) and we took enforcement action. We carried out a focused inspection only checking the action the provider had taken in the safe and well-led sections previously rated as inadequate, the service was then rated as requires improvement (report published 15 July 2019). Requirement actions remained in place in the effective and responsive sections. The provider had already had a condition placed upon its registration due to concerns at an earlier inspection. The condition required the provider to send regular reports to CQC to show what they would do and by when, to improve. CQC had received reports as required.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations and the conditions applied to the providers registration will be removed.

Why we inspected: This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up: We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

Trecarrel provides accommodation with personal care for up 44 people. There were 30 predominantly older people using the service at the time of our inspection.

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

Medicine systems and processes were improved. People had received their medicines as prescribed. There had been no missed doses of medicines since our last inspection.

There were sufficient numbers of staff to ensure people’s needs were met. There were some vacancies but a consistent group of the providers own agency staff were supporting the vacant shifts.

Risk assessments were in the process of being fully reviewed by the new manager. They provided staff with sufficient guidance and direction to provide person-centred care and support.

Audits were carried out regularly to monitor the service provided. Actions from these audits were being completed to further improve the service. The latest report received from the service, in accordance with the conditions on their registration, showed an improving picture of clear management and governance in the areas of concern such as staff supervision and support.

Visiting healthcare professionals told us, “[Managers name] is a great asset to Trecarrel. They are doing well. There are still issues with communication. We arranged for special equipment to be delivered to use for a specific person. We found this had not been used and senior staff were not aware of it. The manager is aware now and so hopefully this will be sorted.”

Rating at last inspection and update:

We carried out an unannounced comprehensive inspection of this service on 1 May 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Trecarrel on our website at www.cqc.org.uk.

Why we inspected: This focused inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up: We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Trecarrel on our website at www.cqc.org.uk.

People’s experience of using the service:

Some people were not all able to fully express their views therefore they were not able to tell us verbally about their experience of living at Trecarrel. Therefore, we observed the interactions between people and the staff supporting them.

The registered manager and staff knew people well and understood their likes and preferences and health needs. Staff were caring and kind. Relatives told us they were welcome at any time and any concerns were listened and responded to.

Due to the concerns found at past inspections, Trecarrel is under a condition of its registration to report to CQC each month on a variety of areas. Whilst we found some improvements in the service since the condition was set in September 2018, the registered manager was not complying with all aspects of the condition. Some required audits had not been carried out. We found some concerns from the last inspections continued to be an issue.

People did not always receive their prescribed medicines. Two people had not received three doses of their prescribed medicines due to the service having run out.

People were provided with the equipment they had been assessed as needing to meet their needs. For example, pressure relieving mattresses. However, the process for ensuring these mattresses were always set correctly was not robust.

There were not always staff available in communal areas to ensure people’s needs were always met.

Not all staff had received mandatory training and support to enable them to carry out their role safely. Some staff training was out of date. One to one supervision for some staff had not taken place and no staff had received an appraisal.

Quality monitoring systems were in place however, these were not always effective. Concerns found at this inspection had not been identified by audits. The registered manager held three separate quality assurance reports. One from an external consultant, one from the local authority and an internal Cornwallis Care action plan, all of which identified many of the issues identified at this inspection. Actions required had not been taken in a timely manner and opportunities to improve Trecarrel had been missed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. However, the registered manager was not clear on which people were subject to a Deprivation of Liberty and which were not.

There was a warm, friendly and welcoming atmosphere. People’s wellbeing was promoted.

The service had pictorial signage which helped support people living with dementia to orientate themselves around the building. Bedrooms were clearly individualised with pictures that were meaningful to each person.

Activities were provided to people on a one to one basis and in small groups during the week. Planned entertainers visited the service.

Staff were recruited safely. There were a number of staff vacancies at the time of this inspection. There had been 12 new staff commence working at Trecarrel in the month before this inspection. This has impacted on the staffing experience levels.

The environment was safe and people had access to equipment where needed.

Rating at last inspection: At the last inspection the service was rated as Requires Improvement (report published 2 November 2018. The rating has been changed to overall Inadequate.

We are placing the service in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. 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.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Why we inspected: This was a planned inspection based on the rating at the last inspection. At our last inspection we rated the service Requires Improvement. Conditions are in place on the service’s registration with the Care Quality Commission (CQC) . The conditions require the registered manager to send a report to CQC each month regarding concerns found at past inspections. Information has been regularly received about aspects of medication, infection control, care plans including risk assessments, staff supervision and training. One audit required by the condition had not been put in place. Prior to this inspection we were provided with anonymous information of concern regarding low staffing levels, medicines management concerns and that some people were not receiving appropriate care to meet their needs. We specifically reviewed these concerns and identified breaches of the regulations which are detailed in the main report.

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.

Follow up: We will continue to monitor the service through the information we receive 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

The service was last inspected in July 2018 and was rated as Inadequate. In July 2018 we received serious concerns from health and social care professionals about the care that people received. The concerns were in relation to, personal care needs not being met, care plans and risk assessments were not in place for some people, medication, nutrition, staffing levels, staff culture, staff training, moving and handling concerns, infection control practices, lack of confidence in record keeping, and concerns regarding leadership of the service. Due to the service being rated inadequate it was placed in ‘special measures.’ Due to this, we imposed conditions on the providers registration to provide us with a monthly audit to provide assurance in how the service would address its shortcomings.

This comprehensive inspection took place on 3 October 2018 and was unannounced. Two inspectors and a Specialist Advisor with an Expert by Experience visited the service. We had received form the provider regular audits which outlined what action they had taken since the last inspection in July 2018.

The findings of this inspection demonstrated that the provider and management team had worked in an open and transparent manner. The provider had complied with four breaches of regulation. This included in the areas of ensuring care plans and risk assessments were in place, nutritional needs had been met, mental capacity procedures were being followed, staff were receiving the appropriate induction, supervision and training, infection control processes were more robust, and repairs had been undertaken to the premises to ensure people’s safety.

The provider acknowledged that further work needed to be undertaken to ensure that new systems and process were imbedded. For example, at this inspection we still found that some records were not consistently being completed, such as monitoring records. Some records would benefit from expansion to ensure they captured the persons physical, emotional and social needs, for example care plans and food and fluid charts. We also did not see any activities provided during the inspection, and feedback from relatives and people was that they wished there was more to do to occupy their time. There was no evidence people’s preferences were taken into account when organising their routines. We have identified a repeated breach of regulation in this respect.

The provider had commissioned an independent consultancy company to provide an overview of the auditing systems in all of their services. They have commissioned this work as an ongoing project as the provider wanted to ensure that effective auditing systems were in place to be proactive in identifying any future short comings in the service at a much earlier stage.

During the inspection we spoke with staff, people and relatives. All spoke of the need for change at Trecarrel Care Home and were positive in how the senior managers had approached this, and all felt that as a result the care of people had “improved significantly.” Staff said they felt more supported. All agreed that this remains “early days” and that the changes needed to be imbedded in all aspects of the service.

In discussion with health and social care professionals all spoke of the improvement to peoples care at the service. They also commented about the improvements in the staff team, “The atmosphere is heads up not eyes down now. The senior carers are working much better now too” and “I have a lot of faith in the staff that they want to make a difference.”

This inspection identified that there was an issue regarding the staff deployment around the service. This meant that there were substantial periods of time when people were isolated in communal areas and not supported by staff. We spent time in the two lounges and were concerned that staff contact with people was when they had a task to perform, for example providing meals, drinks or medicines. We were also concerned that people were not able to access the call bell facility independently to request assistance when needed in the communal areas. In discussion with the provider, he agreed to review the staffing deployment around the service to ensure that sufficient staff were deployed to meet people’s care needs at all times. We have identified a repeated breach of regulation in this regard.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (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. Following the July 2018, the clinical lead director for the organisation oversaw the management of the service. They appointed a new manager on the 14 September 2018 to oversee the management of the service. The manager has not yet submitted a registered manager application to the CQC.

We acknowledge that the care for people had improved and that people were at less risk. However, the changes made have been made quickly and have not had time to instil to ensure long term significant change. The imposed conditions on the providers registration remain in place to ensure that the focus of the changes needed and the progress made continues. Two repeated breaches of regulation have been identified. Therefore, the overall rating of this service has improved from inadequate to requires improvement.

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.

The service was last inspected in November 2016 and was rated as Good. In July 2018 we received serious concerns from health and social care professionals about the care that people received. The concerns were in relation to, personal care needs not being met, care plans and risk assessments were not in place for some people, medication, nutrition, staffing levels, staff culture, staff training, moving and handling concerns, infection control practices, lack of confidence in record keeping, and concerns regarding leadership of the service. Due to these concerns we brought our inspection forward. The inspection found significant concerns at the service.

This comprehensive inspection took place on 17 and 18 July 2018 and was unannounced. Two inspectors and a Specialist Advisor visited the service on the 17 July 2018. An inspector visited the service on the 18 July and met with the senior management team to discuss our findings of the inspection.

The service is required to have a registered manager. Following the safeguarding concerns being raised the manager was no longer employed by the organisation. On being informed of the concerns, the provider promptly deployed their operational management team to address the concerns and support the service. On the 9 July 2018 an interim manager was appointed at the service. Following the inspection, the operational manager clinical lead was appointed to manage the service as they had more experience to address the level of concerns at the service.

Some care staff had not received any training in safeguarding and had limited or no knowledge about the safeguarding process and how to recognise potential signs of abuse or mistreatment.

Some people’s care plans, were not effectively updated to ensure they were reflective of people's current care needs. Following commissioner’s reviews of people’s care needs, it was evident that some people’s health needs had changed. This meant that people’s health needs had not been reviewed appropriately by the service to ensure they could continue to meet the person’s current health and care needs.

People’s risks were not safely managed at the service. For example, a number of people were at risk of falls or risks in relation to their dietary needs. There was no relevant risk assessment in place or documentary evidence to support how the risks could be minimised to keep the person safe. Consultation with those involved with the person was not evident. Therefore, we were not assured that risks had been properly considered and addressed.

The interim manager had developed a new handover system as they were aware that, due to the lack of accurate care plans, staff had limited guidance, information or direction in how to meet people’s needs. The interim manager was aware that this needed to be developed further.

The Local Authority systemic safeguarding meeting raised concerns about the safe administration of medicines at the service. Due to this a community pharmacist visited the service on the 16 July 2018. They undertook an inspection and identified where further action was needed to ensure the safe management of medicines. We reviewed their notes and inspected medicines and found the same issues as the community pharmacist.

The senior management team were unable to identify which person had been subject to a mental capacity assessment. They were also unable to evidence where any applications had been submitted to the Deprivation of Liberties Safeguard (DoLS) team. The clinical lead was able to inform us that they had identified two people who had conditions attached to their DoLS authorisation and these conditions were not being met. This meant it was not possible to understand what decisions the service had taken on behalf of others or to assess whether these decisions were in the person’s best interest and the least restrictive available. In addition, where conditions had been approved these were not being met to ensure a person received care in the manner agreed.

People were not protected from the risks associated with cross infection. Due to concerns in respect of the environment the provider had arranged for an external contractor to come into the service to provide a deep clean which was in progress on the first day of our inspection.

Staff had not received infection control training and lacked knowledge, skill and expertise in this area. For example, the service had shared slings to use when transferring people. These examples demonstrated that there continued to be a risk of cross infection.

Cornwallis Care Services Ltd had an organisational induction process for new staff, but it had not been followed. Staff said the induction was not completed.

People were not always supported by staff who had received training to carry out their role effectively. Training records showed that there were significant gaps in training for care staff. For example, moving and handling training. Staff confirmed they had been in post for “some months and had been using equipment and supporting people to transfer since they started work. The lack of training and induction meant that staff did not have the correct skills and knowledge to safely care for people’s needs.

Health and social care professionals had raised concerns prior to the inspection that the service was not following advice that they provided. We found that monitoring records were not consistently completed so that it was not possible to understand the care that was being provided and whether people’s health concerns were being addressed appropriately.

Some people had significant weight loss at the service. This had not been identified previously as people’s weights had not been monitored and food and fluid charts not completed consistently. Due to this the interim manager implemented a paper record of food and fluid chart. This demonstrated that the previous system for monitoring people’s wellbeing was not safe and placed people at risk.

People spoke to us about staff fondly. However, people’s privacy and dignity was not always respected. During the inspection we spoke with staff, people and relatives. A recurring theme in our conversations was one of a ’chaotic’ situation. This was born out by our observations, particularly in shared areas of the service. We found the service was crowded with little room for people to have privacy or quiet time without going to their rooms. Due to the crowded situation staff found it difficult to observe what was happening and there were occasions when staff failed to notice when people needed support.

There were concerns about the environment. We checked the temperature of water coming from taps and found that the water temperature in some areas were too hot and people were at risk of scalding.

There were some activities arranged by Trecarrel for people. There were no evidence people’s preferences were taken into account when organising their routines.

There had been a number of staff changes at the service since February 2018. There had been management changes and some new staff had been recruited. With a lack of leadership, new staff had not receiving a completed induction and staff in general had lacked access to training and supervision. Therefore, they were unable to provide effective care that met the needs of the people they supported. There was ineffective communication between the senior managers and to staff and the people they supported. Health and social care professionals also gave a mixed response to the manager’s approach and how the service responded to advice given to ensure people’s needs were met.

Due to the safeguarding concerns the provider increased staffing levels at the service. Staff said they felt there were sufficient staff levels on duty to meet people’s current care needs. The rotas demonstrated that there was a high reliance on agency staff to cover staffing levels at the service. It is of concern that as there was a lack of up to date care records staff were unaware of people’s current care needs. An agency worker told us “You just have to ask carers and hope they know what you need to do.” This meant that people were being cared for by staff who were unaware of their care needs and how they needed support.

Recruitment systems were not always robust. We found that not some new staff did not have all the relevant pre-employment checks completed before starting work.

Records required by the service had not been kept up to date. For example, care records, finance records and records relating to the overall running of the service. The last completed accident/incident occurred in December 2017. The senior managers were aware that incidents have occurred in the service since that time but there were no records to evidence this at the inspection.

Peoples records were not stored securely and therefore people’s privacy was not respected.

The organisation had a quality assurance system in place to make sure that any areas for improvement were identified and addressed. The operations manager, who was responsible for the overall monitoring of the safety and quality of the service met with the manager eleven times from March to June 2018. In addition, the nurse consultation met with the manager on ten occasions. The operations manager said that the visits were part of the managers induction. What is of concern is that whilst the manager met with both the operations manager and nurse consultant regularly that issues of concerns were not identified or monitored. Therefore, checks carried out by the operations manager and nurse consultant, had also failed to identify where improvements were required.

The provider has implemented an action plan to address the systemic safeguarding concerns.

This unannounced comprehensive inspection took place on 23 November 2016. The last inspection took place on 10 May 2016. There were breaches of the legal requirements at the last inspection. We were concerned that a new care plan format had not been fully implemented and some care plans did not contain sufficient individualised information to effectively guide and direct staff to meet people’s needs. There were gaps in staff training provision which meant staff skills and knowledge may not have been up to date. Recruitment and induction processes were not always robust. One person was found working at the service without Disclosure and Barring Service checks and sufficient references having been sought. The service did not have a registered manager in post at the time of the last inspection and there were not effective processes in place to assess and monitor the quality of the service provided.

Following the inspection in May 2016 the provider sent the Care Quality Commission an action plan outlining how they would address the identified breaches.

We were concerned that some people living at the service had bedroom doors which were locked and did not have door handles that enabled people to easily open their own door. People did not hold the keys to their locked bedrooms but needed to ask staff to open their doors when required. Upstairs there was a coded lock on the landing leading to bedrooms that were all locked with a key. Staff were not always present upstairs where people were living with dementia and were independently mobile. No having easy access to their bedrooms did not support people’s choice and independence. One person had fallen upstairs and was found on the floor by staff. The registered manager assured us they were confident that the people living upstairs were appropriately placed as they preferred the quieter environment. However, they agreed they would review the locked bedroom doors with a view to making them more accessible to people.

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. Staff took time to chat with people every time they passed.

We looked at how medicines were managed and administered. We found it was possible to establish if people had received their medicine as prescribed. Regular medicines audits were consistently identifying if errors occurred.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met.

Staff were supported by a system of induction training, supervision and appraisals. Staff knew how to recognise and report the signs of abuse. Most staff received training relevant for their role and there were opportunities for on-going training support and development. More specialised training specific to the needs of people using the service was being provided for most staff. For example, dementia care training. Staff meetings were held for all staff teams. These allowed staff to air any concerns or suggestions they had regarding the running of the service and improved communication between management and staff teams.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored people’s weight to help ensure they had sufficient intake of food.

Care plans were in the process of being transferred to a new more person centred format. Three quarters of the care plans were now in this new format. We reviewed both new and old format care plans. Information in a few old format care plans was not so well organised and did not always contain accurate and up to date information. All care plans had been regularly reviewed and mostly reflected people’s changing needs. Where appropriate, relatives were included in these reviews.

Activities were provided on a regular basis by a dedicated activities co-ordinator. There was a programme or varied activites advertised throughout the service.

The registered manager was supported by two deputy managers and a team of senior care staff. The registered manager received regular supportive visits from the provider.

The service was found to have met the breaches of the regulations from the last inspection.

Two inspectors carried out this unannounced focused inspection on the 10 May 2016. At this visit we checked what action the provider had taken in relation to concerns raised during our last inspection in October 2015. At that time we found breaches of legal requirements in respect of the following areas: a lack of infection control measures were in place: a lack of training and supervision for staff: care plans were not up to date and auditing systems were ineffective.

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

The service is required to have a registered manager and at the time of our inspection there was no registered manager 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. The provider had appointed a new manager January 2016. The manager had not yet submitted their registered manager application to the Commission but reassured us this was in process.

We had received anonymous concerns about how people were cared for at Trecarrel Care Home. At this visit we looked at the anonymous concerns raised. They related to a lack of individualised detail in people’s care plans to ensure their needs were met, concerns in relation to medicines, staffing levels, staff support and the changes that had occurred at the service since the appointment of the new manager.

We found new processes and systems had been introduced. For example, infection control processes were now in place and being followed. Staffing levels had been reviewed which had led to the introduction of an additional member of staff on the newly introduced ‘twilight shift’. Staff supervision was now in place.

We noted that further work was needed in certain areas of the service. For example, a new care plan format had been introduced and a review of people’s care needs was commencing. The care plan formats needed to be developed further to include areas of care around medicines and mental capacity. Currently staff had reviewed four people’s plan of care and aimed to have reviewed every person living at Trecarrel within a three month timescale. We also noted that a training matrix had been developed. From this it was evident that there were gaps in staff training which need to be addressed so that staff skills remained up to date.

We had received anonymous concerns about the new systems that the manager had introduced. Staff t stated that initially it was difficult to acknowledge or accept that changes were needed. They were now able to see the positive impact of some of the changes that have been implemented. Staff sickness had lowered and staff said they felt morale had improved. Some comments from staff included; “We’ve needed this for a while”, “All the changes are good. Some staff haven’t been ok with the changes but we need a leader” and “It’s going in the right direction.”

It was acknowledged from the manager and from all staff at the service that a lot of changes had been needed and some of these changes were difficult to acknowledge or accept. However work in continuing to improve communication within the Trecarrel staff team is still needed. This would provide staff with sufficient information to understand the rationale around why change is needed so that staff can understand the reasoning. Meetings with staff, relatives and people are now in progress so that there is opportunity for all to share their views of the service and be involved in its development.

From this inspection we concluded that work in the areas of care planning, undertaking reviews, staff training, induction, and gaining feedback from other parties regarding the service remains on-going. Whilst we appreciate that changes are in progress the systems currently in place are not able to evidence their effectiveness over time. A longer term track record of consistent good practice is needed before we can be confident that the changes made are demonstrating that the service is running effectively.

At this inspection we found the recruitment process was not robust. We found that one person was working on shift with no Disclosure and Barring Service check being completed and insufficient references had been obtained for two newly recruited staff. Due to this issue being raised at the previous inspection, this meant that recruitment processes were not robust and could place people at risk of harm. We therefore issued an additional breach of Regulation in this regard.

We saw staff providing care to people in a calm and sensitive manner and at the person’s pace. When staff talked with us about individuals in the service they spoke about them in a caring and compassionate manner. Staff demonstrated a good knowledge of the people they supported. We saw many examples of kindness, patience and empathy from staff to people who lived at the service.

We saw the service’s complaints procedure which provided staff and people with information on how to make a complaint.

We found four breaches 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.

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.

Is the service safe?

At the time of the inspection people told us they felt safe. Systems were in place to help the manager and staff team learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. Staff showed a good understanding of the care needs of the people they supported.

Trecarrel alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service.

Trecarrel had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS), and further staff training was planned. This helped to ensure that people's needs were met.

Is the service effective?

At the time of the inspection people were not always involved in writing or reviewing their plans of care. During our inspection 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.

Specialist dietary needs had been identified where required. Care plans were up-to-date.

We saw that there was good liaison and communication with other professionals and agencies to ensure people's care needs were met.

Is the service caring?

We spoke with people being supported by the service. We asked them for their opinions about the staff that supported them. At the time of the inspection feedback from people was positive, for example, 'I find the staff to be friendly, helpful and kind'.

Trecarrel had regular support from the GPs from the local GP practices and other visiting health professionals. This ensured people received appropriate care in a timely way.

Is the service responsive?

At the time of the inspection many people who lived at Trecarrel had complex health needs and were either not able, or chose not to join in group activities. There was evidence to show that people were routinely offered one-to-one time or group activities.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

At the time of the inspection Trecarrel did not have a registered manager, but the manager confirmed they were in the process of submitting an application to be the registered manager.

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

The service had a quality assurance system, and staff were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We spoke and met with people who lived at Trecarrel. People we spoke with told us, 'There [staff] so patient and kind', 'kind and helpful' and 'very good, very well looked after'. One relative told us they thought the home was 'excellent'.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Some people who used the service where able to tell us their views about the care and support they received. However, the people who lived at Trecarrel Care Home predominately had dementia type illnesses and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences of people, we used our Short Observational Framework for Inspection tool (SOFI). The SOFI tool allowed us to record how people spent their time, the type of support they received and whether they had a positive experience.

People experienced care, treatment and support that met their needs and protected their rights.

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

There were enough qualified, skilled and experienced staff to meet people's needs.

There was an effective complaints system available.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and other

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

The home was clean, tidy and free from odours. Refurbishment had taken place with new carpets in communal areas and some bedrooms. We also noted some new furniture was in place.

Staff were seen to be busy during the whole inspection due to the care needs of people who lived at Trecarrel. Despite this a relaxed and calm atmosphere remained and we observed that the staff treated people with respect and showed empathy and compassion for the people they cared for.

We saw the staff offered people choices of how they spent their day. For example, what time they got out of bed, where they sat in the home, activities they took part in and what they wanted to eat. Staff were patient and demonstrated they had a knowledge of people's care needs and their preferences and choices.

People were offered a wholesome and nutritious diet from the planned menu which afforded them a choice at each meal. We were told the food was good.