We carried out a review of the data available to us about Trevone House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Trevone House, you can give feedback on this service.
Trevone House has two registered places (known as ‘well-being suites’) within the service providing the regulated activity of accommodation for persons who require nursing or personal care. The well-being suites have been commissioned primarily to support young people who require additional support following a mental health assessment or as a step-down from secure accommodation. At the time of our inspection there were two young people using the service.
People’s experience of using this service and what we found
Since our last inspection, the registered manager had taken action to review each person’s risk and medicine management plans, implemented effective safe infection control and developed quality assurance systems to monitor the quality care being delivered to young people who live at Trevone House.
Staff had access to comprehensive care and risk management plans to guide them in the strategies to support young people. There was a balanced approach to support people to reach their potential and manage any associated risks. Effective and clear systems had been implemented to report any concerns or incidents to the registered manager and the commissioners.
Safe medicines management processes were in place. The provider had sought advice from the local health protection team and has implemented safe infection control practices which reflect current guidance.
Young people were supported by staff who knew them well. The provider had ensured that all staff had been suitably vetted and trained to support young people.
The managers and staff were passionate about supporting young people to develop holistically. Relatives praised the support of Trevone House and how staff had taken steps to implement safe strategies to enable their family member to achieve their goals.
Governance and auditing processes had been implemented to enable the register manager and provider to monitor the service and drive improvements.
The provider was reviewing their policies to reflect the working arrangement within Trevone House.
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 requires improvement (published 22 July 2022).
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 9 June 2022. 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 and governance.
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.
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.
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 Trevone House on our website at www.cqc.org.uk.
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
The provider was unable to identify and act on shortfalls of the quality of care being provided in a timely way as they did not have an effective oversight of the service or quality assurance systems and protocols. This meant that the provider and manager could not be assured that young people received safe and effective care and support.
Staff did not always have access to comprehensive care records of care to guide them in the strategies to support young people. The assessment and agreed approaches in the management of young people’s personal risks were not clear. Comprehensive care plans reflecting the holistic care requirements of young people and their views and personal goals were not in place.
Safe infection control and medicines management practices had not been maintained and implemented which put young people at risk.
Staff felt trained and supported to carry out their role. However, the provider had not ensured that agency staff had the skills to support young people with complex needs.
Staff understood their role to protect young people from abuse and harm and how to support young people with heightened emotions or in a crisis.
Young people were supported by sufficient numbers of staff who provided them with continual support and helped them their personal wellbeing and objectives such as attending college.
Young people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. All incidents were reviewed to identify any trends or concerns.
Relatives praised the ethos of the service and the kindness of staff. Young people were treated with respect and in a non-judgment manner.
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 27 April 2021 and this is the first inspection.
Why we inspected
This service had not been inspected since their registration; therefore, this inspection was carried out to gain assurances about the quality of care and systems used to monitor and manage the service.
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 identified breaches in relation to the safe care and treatment of young people and provider’s quality assurance systems.
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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.