Trepassey Residential Home

Updated 5 February 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 21 January 2021 and was announced.

Updated 5 February 2021

This inspection took place on 3 and 4 May 2018 and was unannounced.

Trepassey 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.

During the inspection, there were 12 people living in the home. People had moved to the newly built extension the day before the inspection took place. The new extension provided 15 bedrooms over two floors and a lift was available between the floors. Due to the location, both floors led outside without the need for people to use stairs or the lift. The registered manager told us the older part of the home would now be fully refurbished.

At the last inspection in March 2017, the registered provider was found to be in breach of Regulations due to risks regarding water temperatures and ineffective audit systems. The provider completed an action plan to show what they would do and by when to improve the key questions of whether the service was safe and well-led, to at least good. We found that water temperatures were within safe ranges, however other concerns were identified and although the registered provider was no longer in breach of Regulation, we made a recommendation regarding this in the main body of the report. Systems in place to monitor the quality and safety of the service had improved.

A registered manager was in post and feedback regarding the management of the service was positive. 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.

Not all risks had been assessed appropriately. For example, a fire risk assessment of the new building had not been completed prior to people moving in and risks posed by balconies had not been assessed prior to their use. After the inspection we received confirmation that the fire risk assessment had been completed and no major concerns had been identified. Records showed that there were a range of other internal and external checks that had been completed to help ensure the building and equipment remained safe.

Staff felt supported in their role and had completed a comprehensive induction when they started in post and had access to regular training. However, not all staff had received regular supervisions and annual appraisals had not been completed.

Most safe staff recruitment procedures were followed when recruiting staff. Relevant checks had been recorded and all but one staff member had provided a full employment history. The registered manager agreed to ensure the staff member provided this.

People we spoke with told us they felt safe living in Trepassey. Staff were knowledgeable about safeguarding processes and appropriate referrals had been made to the local authority for investigation. There were sufficient numbers of staff on duty to meet people’s needs and help maintain their safety. Accidents and incidents had been recorded and reported appropriately. The registered manager maintained a log of all accidents and reviewed these every month to help identify and learn from potential themes or trends.

Medicines were ordered and administered safely. Staff had received training and had their competency assessed in this area. However, temperatures were not monitored in all areas where medicines were stored and the registered manager agreed to ensure thermometers were available in all areas. We also found that there were no protocols in place to guide staff when to administer PRN (as and when required) medicines to ensure that people received them consistently and when needed.

People at the home were supported by staff and other external health care professionals to maintain their health and wellbeing. Staff made appropriate referrals for advice and people told us they saw the doctor quickly if they were unwell.

Records showed that applications to deprive people of their liberty had been made appropriately. Two authorisations were in place and staff were aware of these. Staff had a good understanding of the Mental Capacity Act 2005 and we saw that consent was sought and recorded in line with this legislation.

People told us they had enough to eat and drink and we saw that drinks and snacks were readily available to people throughout the day. A choice of meals was always available. Risk regarding malnutrition had been assessed and measures had been put in place to reduce risk to people.

Staff were kind and caring and treated people with respect. We observed staff provide support in an unhurried and kind manner and people’s dignity and privacy was protected. Interactions between staff and people living in the home were warm and familiar and it was clear that mutually respectful relationships had been developed.

Staff knew the people they were caring for, including their care needs and preferences. This enabled people to be supported by staff that knew them well and could provide care based on their individual needs and preferences. People told us they had choice regarding their care and how they spent their day. People and their relatives were involved in care planning and relatives told us they were aware of the plans.

People were supported in a way which promoted their independence. Equipment was also in use within the home when people needed them, to help maximise their independence.

There were no restrictions in visiting and relatives told us they were always made welcome. This helped people to maintain relationships made prior to moving into the home and prevent isolation.

Care plans were detailed and reflected people’s current needs. They were reviewed regularly and written in a person centred way. They included information on how people wanted to be supported, their preferences in relation to their care and what was important to them. Staff had completed ‘Six Steps’ training to enable them to provide effective care to people at the end of their life.

A range of activities were provided by staff both in the home and within the local community and people told us they enjoyed the activities.

A system was in place to manage complaints and we saw they had been investigated and responded to appropriately. Systems were in place to gather feedback from people, such as meetings and quality assurance surveys. It was clear that feedback received was acted upon. Relatives told us they were kept informed of any changes within the home.

Systems were in place to ensure the provider was kept informed and maintained an oversight of the service.

The registered manager had a good understanding of their responsibilities, including the need to submit statutory notifications about certain incidents. The registered manager had also ensured that improvements had been made to address issues that had been raised at the last inspection. Ratings from the last inspection were displayed as required.