Little Trefewha Care Home

Little Trefewha Care Home is a residential care home providing personal care to up to 21 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 21 people using the service.

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

People received their medicines as prescribed. Staff recorded administration on to paper Medicine Administration Records (MAR) and these were regularly audited. Some people had been prescribed pain relieving patches. Staff were not always recording on the body map where these had been place. We have made a recommendation about this in the safe section of this report.

At our last inspection we found the recruitment process was not entirely robust at our last inspection and we issued a requirement notice regarding this. At this inspection we found people had been recruited safely.

The premises were clean with no malodours. The building was in need of some re-decoration and there was a programme in progress to address this. At the time of this inspection there was a contractor building a covered area outside for people to sit in the shade.

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.

Little Trefewha had enough staff available to meet people's needs and ensure their safety. Staff were happy and many had worked at Little Trefewha for many years. People told us, “Staff are lovely, I have no complaints. Yes, there are enough staff to help me,” “There are always plenty of staff on duty and they really look after you, couldn't ask for better” and “Staff are local to the home and have been in their roles for many years, they're very efficient”.

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. Guidance in 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.

Food was freshly cooked on the premises and looked appetising. There were staff available to support people at mealtimes where needed. People were positive about their meals.

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

People, staff and relatives were asked for their views and experiences by the registered manager and the provider. Staff meetings and residents meetings were held to share information and seek people’s views. Comments from people included, “I like living here,” “Carers do a good job, they all do their best, I’m quite happy here, I feel part of the furniture” and “I’m lucky to be here, there is plenty of choice of entertainment and food”.

Relatives' comments included, “(Person’s name) has settled in very well, staff are approachable and responsive, I’m happy that (Person’s name) is safe and happy here” and “We are kept well informed about (Person’s name) care. Any change in their condition is reported to us and external medical help is sought if necessary”.

The registered 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 registered manager 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 2018).

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 30 November 2018. A breach of legal requirements was found in relation to recruitment processes being used at that time.

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 and well-led.

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 Little Trefewha 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.

Little Trefewha Care Home is a residential care home providing personal care to 21 people, some of whom are living with dementia. People are primarily aged over 65 years. At the time of the inspection 20 people lived at the service. The home was on two floors with a range of communal areas. These included dining spaces and lounges.

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

The medicines system was not managed effectively. For example, medicines which were administered were not always labelled correctly. Types of medicines which were handwritten on to medicine administration records were not countersigned by two members of staff to confirm instructions were correct. Otherwise the medicines system was well organised, there were no other errors, and staff received suitable training. People said they received their medicines on time.

The service was generally managed effectively. However, systems to monitor service delivery were not always satisfactory. For example, medicine audits had not picked up and recommended changes to the system in regard to the shortfalls we have highlighted.

People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests. Policies and systems in the service supported this practice. However we have made a recommendation that care records and planning should be more detailed where people had limited or lacked capacity.

The service had suitable safeguarding systems in place, and staff had received training about recognising abuse.

Risk assessment procedures were satisfactory so any risks to people were minimised.

Staff were recruited appropriately. For example, suitable references were obtained, for example when new staff had previously worked in a caring capacity. Checks from the Disclosure and Barring Service were obtained.

Staffing levels were satisfactory. We observed people receiving prompt support from care staff when required. People said they were happy with the support they received and they did not have to wait too long.

The building was clean, and there were appropriate procedures to ensure any infection control risks were minimised.

The service had suitable assessment systems to assist the registered provider to check they could meet people’s wishes and needs before admission was arranged.

People received enough to eat and drink. Some people said the quality of meals was good and they received a choice about the meals they received.

Care planning systems were satisfactory. Care plans outlined people’s needs and were reviewed when people’s needs changed.

People received support from external health professionals and were encouraged to live healthier lives.

People said they received support from staff which was caring and respectful. Care promoted people’s dignity and independence. People were involved in decisions about their care.

People had the opportunity to participate in activities.

People felt confident raising any concerns or complaints. There had not been any complaints about the service since the last inspection.

Staff induction procedures were satisfactory. For example there was suitable information to show staff had received a comprehensive induction. Staff received suitable training to carry out their roles. Suitable records were available to demonstrate staff received regular one to one supervision with a senior member of staff.

People, relatives and staff had confidence in the management of the service.

The team worked well together and had the shared goal of providing a good service to people who lived at the home.

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

Rating at last inspection

The last rating for this service was requires improvement (published 30 November 2018). 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 in regard to the previous breach of regulation. However, we found another concern so the provider was still in breach of the regulations. We have used the previous rating and regulatory action taken to inform our planning and decisions about the rating at this inspection.

Why we inspected

This was a planned inspection based on the previous rating. We found evidence that the provider needs to make improvements. Please see the Safe, and Well Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to the management of medicines. Please see the action we have told the provider to take at the end of this report.

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

At this inspection we found that, on the whole, satisfactory action had been taken, although we still had concerns about staff recruitment checks. As a consequence, we have issued the service with a statutory requirement to improve recruitment checks and this has had an overall impact on the rating of the service, although other aspects of the service are seen as good, and people were happy with the care they received.

Little Trefewha 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. Little Trefewha accommodated up to 21 people, and there were no vacancies at the time of the inspection.

The service had a registered manager. 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.

The service was viewed by people we spoke with as very caring. We received positive comments about the service. For example, we were told, "Nothing is too much trouble for the staff," and "They are always doing something to make you more comfortable. " A relative told us said, "I find this home wonderful, and a staff member said, "Residents always come first," and "Care is very good. Everyone works to the best of their ability. When we raise concerns they are dealt with." Everyone we saw looked well cared for. People were clean and well dressed. The service provided some activities.

People told us they felt safe. For example, one person told us, "I feel safe because the staff are very friendly to me." The service had a suitable safeguarding policy, and staff had been appropriately trained to recognise and respond to signs of abuse.

People had suitable risk assessments to ensure any risks of them coming to harm were minimised, and these were regularly reviewed. Health and safety checks on the premises and equipment were carried out appropriately.

There were enough staff on duty to meet people's needs. Although we had no concerns about the conduct of any staff member we were concerned about recruitment procedures for staff members. For example, an employment history was not always given on staff application forms, and references were not always taken up from the candidates most recent employer and when they have not recently worked in a caring capacity.

Staff members received an induction. However, there was no record that some staff, who had not worked in health or social care, had commenced or completed the Care Certificate. This is a set of national standards for staff coming into the health and social care sector. Although there was a record all staff had received an induction, we have made recommendation that staff without recent care experience complete the Care Certificate. Overall staff had received suitable training. However, some staff members did have gaps in the receipt of training, for example about adult safeguarding, first aid and dementia.

The medicines' system was well managed, medicines were stored securely, and comprehensive records were kept regarding receipt, administration, and disposal of medicines. Staff who administered medicines received suitable training. Some people self-administered their medicines.

The service was clean and hygienic. The building was suitable to meet the needs of the people who lived there. The building was well laid out, pleasantly decorated and homely.

There were suitable assessment processes in place before someone moved into the service. These assisted in helping staff to develop care plans. We were told staff consulted with people, and their relatives, about their care plans, although this was not always recorded as taken place. Care plans were regularly reviewed.

People enjoyed the food and were provided with regular drinks throughout the day. Support people received at meal times was to a good standard. Comments about food included: "I thoroughly enjoyed lunch it was beautiful," and, "I'm quite pleased with the food, there are some good options."

The service had well established links with external professionals such as GP's, Community Psychiatric Nurses, District Nurses, and social workers.

Some people lacked mental capacity. Where necessary suitable measures had been taken to minimise restrictions. Where people needed to be restricted, to protect themselves, and/or others, suitable legal measures had been taken. No physical restraint techniques were used at the service. Staff had received suitable training about mental capacity.

The service had a satisfactory complaints procedure. People we spoke with felt they could raise a concern or complaint, and these would be responded to appropriately.

The registered manager was respected and liked by people, relatives and staff we spoke with. The registered manager had a hands on approach. Staff also said team working at the service was good, and team members were supportive and communicated well with each other.

Overall the quality assurance system were generally adequate. However, we have made a statutory requirement regarding employment checks, and the issues we have raised should have been picked up by management if systems are totally effective.

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. Little Trefewha is a care home which offers care and support for up to 21 predominantly older people. At the time of the inspection there were 20 people living at the service. A few of these people were living with dementia. The service occupies a detached house with two floors. There was a stair lift to assist people to the upper floors.

The systems in place for the management and administration of medicines was not entirely safe. The service used medicines that required stricter controls. The records of these medicines did not tally with the stock held at the service. Staff had handwritten medicines on to the Medicine Administration Records (MAR) but staff had not followed their own medicine policy guidance and these entries had not been signed and witnessed by two staff. This did not protect people from the risk of potential errors being made. There were many gaps in the MAR where staff had not signed to indicate if people had been given their medicines at the prescribed times. This meant it was not possible to establish if people always received their medicines as prescribed. Prescribed creams were not dated when opened. This meant staff were not aware when the item should be disposed of as no longer suitable to be used. Some people were self administering their own medicines. Two people did not have appropriate secure storage for their medicines in their bedrooms. Some medicine audits were being carried out and gaps in MAR charts had been identified as a concern in a number of audits. However, there was no evidence that effective action had been taken to help ensure that future events were reduced. No audits were being carried out regarding medicines that required stricter controls. The concerns found with the medicines management at the service had not been identified prior to this inspection.

Fire doors to five rooms were found held open with wedges and ornamental door stops. The provider took immediate action to address the concerns found at this inspection. The door guard devices fitted to two bedroom fire doors were replaced during this inspection as they were not functioning correctly. A number of door guards were not effectively holding the fire doors open due to not having appropriate plates screwed through the carpeting to enable to door guard to hold open safely and securely. This had led to the door guards slipping on the carpeting and closing when people wished their doors to be open. Door wedges had been used by staff to hold doors open. This meant these fire doors would not close in the event of the fire alarm being activated and placed people at risk. We have made a recommendation in this regard in the Safe section of this report.

Staff were not provided with supervision and annual appraisals according to the policy held by the service. However, there were regular staff meetings and staff were able to access informal support whenever needed. Recruitment of new staff was not always robust. Four out of six staff files reviewed only had one reference taken up by the service before the person began to work at the service. This was not in line with the service recruitment policy.

One person had been identified as being at risk of dehydration. The recording of this person’s fluid intake was not always appropriately completed by staff. No totalling or monitoring of these records were evidenced. This meant it was not possible for staff to judge if the person had had sufficient drinks each day.

Audits and checks of the service provided which were carried out, were not effectively identifying concerns found at this inspection.

Residents meetings were held, the last meeting was in July 2017, the last two advertised scheduled meetings did not take place. The registered manager told us this was due to a lack of staff time. The service was not displaying their last inspection report and rating as they are legally required to do. The registered manager addressed this at the inspection.

People and their relatives told us, “This care home has been fantastic, nothing was to much trouble while looking after my Mum. The staff were always helpful and kind,” “ I find the manager open to ideas and suggestions. She appears very caring and aware of individual resident’s needs. She always takes time to listen if I have any concerns for residents, and acts promptly accordingly. The home has always appeared to me well managed” and “Staff appear competent and well trained. I’ve not had reason to doubt their ability.”

The premises were well maintained. Whilst the service was not registered for dementia care, there were people living at the service with early dementia. There was no pictorial signage at the service to support people who may require additional support with recognising their immediate surroundings and increase their independence.

The premises were regularly checked and maintained by the provider. Equipment and services used at Little Trefewha were regularly checked by external contractors to ensure they were safe to use.

We walked around the service which was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes. People were treated with kindness, compassion and respect.

Risks in relation to people’s daily life were assessed and planned for to minimise the risk of harm. People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance. Mandatory training was provided to all staff with regular updates provided. The registered manager had a record which provided them with an overview of staff training needs.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had no staff vacancies at the time of this inspection.

People's rights were protected because staff acted in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards were understood and applied correctly.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Staff supported people where necessary to enjoy their meals. People were positive about the food.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff.

People had access to activities. An activity co-ordinator was not in post but care staff co-ordinated a planned schedule of activities. People were supported to go out in to the local community for walks, attend appointments and enjoy a coffee or fish and chips

The registered manager was supported by a deputy manager, the provider and a team of motivated and many long standing staff.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. We contacted the fire service to advise them of our concerns and have made a recommendation about the regular supervision of staff. You can see the action we have told the provider to take at the end of this report.

We spoke with the provider, the registered manager, two staff and five people who lived at the home. Their comments were mostly postiive and included "the staff are lovely, so kind", "the food is very good" and "we are all just one team". One person told us they felt too anxious to spend time in the lounge area as "I could not get staff to help me to go to the toilet when I needed to go, I had to ask the other people in the lounge to call them, they asked why I needed them (staff), then everyone knew what I wanted, it was embarrassing, so I stay in my room now".

We found the provider sought the views and experiences of the people who lived at Little Trefewha through resident's meetings and in one to one discusssions. People we spoke with felt they could approach the registered manager at any time.

We found the provider had an effective system in place to assess and monitor the service which was provided to people at Little Trefewha.

At the time of our inspection there were twenty people living at Little Trefewha. We spent time observing people and staff during the day. We saw staff knock on people's bedroom doors and wait for an answer before entering, and sought people's permission before providing care and support. We witnessed staff interactions with people which were positive.

We found people's views and experiences had not always been recorded and taken into account in the way the service was provided and delivered in relation to their care.

We saw people's privacy and dignity was respected, and staff were helpful.

People were protected from the risks of inadequate nutrition and dehydration.

We found people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Staff had received appropriate training and supervision.

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 others. Staff records were not being effectively monitored.

We saw staff knock on people's bedroom doors and wait for an answer before entering, which showed people's privacy and dignity was respected. People who used the service said they were able to express preferences and make meaningful choices. For example, people chose when they got up in the morning, where they spent their day, and what they wanted to eat. People's likes and dislikes were known. We saw staff talk with people and observed that they were respectful, friendly and supportive of them. The atmosphere in the home was warm, welcoming and there was a sense of fun.

We spoke to an external professional who said 'it's a really good home'.

From our inspection we found that people experienced care, treatment and support that met their needs and protected their rights.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People who used the service, their representatives and staff were asked for their views about their care and treatment, and they were acted on.