Archived: Trefula House

Updated 24 October 2020

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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We also wished to check that suitable action had been taken following two warning notices issued by CQC after the last inspection. This enforcement action was due to concerns about the registered persons not providing person centred care, and also not ensuring suitable procedures were in place about consent to care for people in line with the Mental Capacity Act 2005.

The inspection was also prompted in part by information shared with CQC about potential concerns about inappropriate referrals to the service and unsatisfactory care practice.

Inspection team:

The inspection team included three inspectors (two inspectors each day,) a specialist advisor (who had experience of dementia care), an expert by experience, a person who has personal experience of caring for someone who uses this type of care service.

Service and service type:

Trefula is a care home with nursing. The majority of people have dementia and / or other mental health needs. People in care homes receive accommodation and personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection:

This inspection was unannounced.

What we did:

We reviewed information we had received about the service since the last inspection. This included details about incidents the provider must notify us about, such as abuse; and we sought feedback from the local authority, and other professionals who work with the service. We assessed the information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During, or after the inspection we spoke or had written contact with five people and two relatives to ask about their experience of the care provided. We spoke with seven members of care staff, the deputy manager, the nominated individual, and one of the director’s of the company. During, and after the inspection we spoke or had contact with seven visiting professionals from health and social care.

We reviewed a range of records. This included thirteen people's care records, and medicine records. We also looked at eight staff files around staff recruitment. We also looked at other records in relation to training and supervision of staff, records relating to the management of the service and a variety of policies and procedures developed and implemented by the provider.

Updated 24 October 2020

About the service:

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