Archived: Trengrouse

We found the following examples of good practice.

There had been an outbreak of Covid-19 at the service, however, the service was now out of isolation. During the outbreak the registered manager had communicated with people, staff and families regularly to ensure everyone understood the measures put in place to help keep people safe.

During the outbreak the organisation arranged for caravans to be situated in the service’s car park and rented two holiday homes. Staff volunteered to move into this accommodation so that they could provide dedicated care and support to the people living at Trengrouse. This also meant they could reduce the potential ongoing risks from the virus to the people at Trengrouse, for the staff and to their own families. Staff wiliness to move into this accommodation evidenced their commitment and dedication to people in their care.

The organisation provided staff with the opportunity to receive psychological support following the outbreak. When staff needed to be absent from work, financial and emotional support was available.

The registered manager worked closely with external healthcare professionals to enable people to have access to appropriate health care and necessary equipment. During the outbreak meetings with health professionals increased to twice a day so that they could ensure that people received the most appropriate care and treatment at all times.

The service had sufficient supplies of Personal Protection Equipment (PPE) and this equipment was available throughout the service. Signage was in place throughout the service regarding the requirement for wearing PPE. Additional signage identified the PPE to be worn when a person was assessed as being at higher risk of infection. Additional PPE had been provided for staff, such as visors, to use during the outbreak. Staff put on and took off their uniforms in a designated area. 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.

The service was clean, hygienic and uncluttered in appearance. Additional cleaning schedules where in place to ensure all infection control risks were minimised and people were kept safe. There were supplies of anti-bacterial wipes around the service to enable staff to use to clean surfaces and bathrooms, after each use, in addition to the increased cleaning routines. There were posters around the service to prompt and remind staff about the infection control procedures in place. All high contact areas were cleaned regularly throughout the day, and night staff also had a cleaning routine.

Procedures were in place regarding self-isolation for people and staff if they showed symptoms of Covid, or who were admitted to the service from the community or other health care provision. The admission procedure had been reviewed and developed to reduce the risk of infection from Covid. The physical environment had also been changed so that there was now a dedicated admission unit so that people could safely self-isolate on arrival at the service. People’s laundry and utensils were cleaned separately to again reduce the risk of infection.

Specific Covid 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.

Since the new Covid restriction for visitors had been changed the service had developed new guidance. This included one designated visitor for each person living in the service. All visitors were required to make appointments and a designated room was made available for visitors and people living in the service. Friends and families were aware of the updated policy on the new restrictions. Where visiting was permitted inside the service for compassionate reasons, for example, for people receiving end of life care, suitable infection control procedures were in place. Visitors were screened for Covid prior to entering the service and were required to wear PPE at all times.

People were supported to speak with their friends and family using IT and the telephone as necessary.

Appropriate testing procedures for Covid had been implemented for all staff and people who used the service. All testing occurred at the service in a designated ‘testing’ room which was accessible by an external door so that staff and visitors did not have to enter the home where people lived. Arrangements had been made to enable people and staff to access the vaccine.

Staff had completed online infection prevention and control and Covid-19 training. The registered manager confirmed training in this area was being continuously refreshed with staff. The registered manager worked with care and domestic staff teams to ensure infection prevention and control measures were followed.

The registered manager had been well supported by the cluster manager, infection control leads and other staff within the service. Two regular agency staff continued to provide continuity of care to two individuals who needed one to one support at all times.

The registered manager had completed risk assessments regarding the environment and risks to staff and people who used the service. The registered manager was aware of staff members who were at increased risk from Covid and risk assessments had been completed to support higher risk staff.

The provider had a detailed contingency plan to manage any further outbreak of the infection.

Trengrouse is a ‘care home’ that provides nursing care for a maximum of 41 adults, with a range of health care needs including dementia, nursing and mental health. At the time of the inspection there were 36 people living at the service. 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.

Trengrouse is situated in the town of Helston. It is a purpose built single storey building with a range of aids and adaptation in place to meet the needs of people living there. It is close to the centre of Helston with links to public transport. There are three separate lounges radiating from a central hub, with peoples rooms leading off from the various lounge areas. All rooms were single occupancy. There was a main dining room but also small dining areas in each lounge. There were a range of bathing facilities in each area designed to meet the needs of the people using the service. There was a central patio area and a garden which people could use if they were being supported.

Risks in relation to people’s daily lives were identified, assessed and planned to minimise the possibility of harm whilst helping people to be as independent as possible. Records included evidence of reviews to make sure changes were being monitored and responded to. Care plans included information about people’s general health and who was involved in the person’s care and welfare.

Some people’s health needs meant they needed to have their food and drink intake monitored to ensure they received sufficient each day. We found the records for monitoring were not always complete. Three records recording people’s food and fluid intake on a daily basis did not include the amount expected on a daily basis. This was recorded in the main care file but had not been applied to the records used by staff. This meant staff were not reminded of the daily amount required which had the potential to affect their judgements. We have made a recommendation about this.

People received care and support that was responsive to their needs because staff had the information to support them. Staff supported people to access healthcare services. These included, social workers, psychiatrists, general practitioners (GP) and speech and language therapists (SALT). Relatives told us the service always kept them informed of any changes to people’s health and when healthcare appointments had been made.

There were sufficient numbers of suitably qualified staff on duty to meet people’s needs and there was less reliance on agency staff to ensure people were familiar with those staff providing care and support.

The way medicines were managed was safe. Staff responsible for the administration of medicines had the necessary competency and skills required. Medicines were stored securely and safely.

Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. There was a wide range of training available to all staff which met the diverse needs of people being supported. Staff were supported through formal supervision.

Staff were supported by the registered manager through regular updates called ‘stand up meetings’. These kept the staff team up to date with any changes and provide any essential information that might be needed to be shared to support peoples care and welfare.

Some areas of the environment required attention. For example some chairs had cushions missing, one chair was heavily stained and a table in the lounge area had no chairs around it and therefore restricted people using this area for some time until one was replaced. We spoke with the registered manager about this and were provided with a maintenance plan for the year which identified when furniture and decoration would be taking place.

Infection control measures were in place. Where people were at high risk of infection staff were knowledgeable about the risk and action to be taken. There was a housekeeping team who told us they had the training and equipment to keep the service clean and understood key issues for infection control. However there was an underlying odour in parts of the service. We shared this information with the registered manager. They told us action was being taken to remove the odour by replacing carpets in some rooms with cushion floor. All staff had infection control training as part of their induction. They then undertook refresher on-line training. A new in-house infection control course is being planned, to reflect the particular needs of people using the service.

Safeguarding procedures were in place and staff had a good understanding of how to identify and act on any allegations of abuse.

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.

The manager used effective systems to record and report on, accidents and incidents and take action when required.

There was a system in place for receiving and investigating complaints. People we spoke with had been given information on how to make a complaint and felt confident any concerns raised would be dealt with to their satisfaction.

People told us the registered manager and the staff team were approachable, friendly and supportive.

The provider had systems in place to monitor the quality and safety of the service.

This unannounced comprehensive inspection took place on 28 February 2017. We previously carried out a focused inspection on 11 November 2016. This was in response to anonymous concerns received that the service was not adequately staffed and not always meeting people’s continence needs. It was alleged that there were strong incontinence odours because people were not regularly provided with personal care. At this inspection the provider had taken action to address these issues and the service was now meeting the requirements of regulation.

People and relatives all spoke positively about the service. They said that people were safe living in the service and that staff were kind, friendly and treated people well. They told us that the registered manager and staff were approachable and they felt listened to.

People received care and support from enough staff to ensure they received prompt and attentive care. Staff had time to chat with people as well as meeting their care and support needs.

People received their medicine on time and in the format prescribed for them.

The service was acting within the legal framework of the Mental Capacity Act (MCA) and Deprivation if Liberty Safeguards (DoLS).

Safeguarding procedures were in place and staff had a good understanding of how to identify and act on any allegations of abuse. Incidents were logged, investigated and action taken to keep people safe. Risks to people’s health and safety were assessed and clear plans of care put in place.

Staff treated people fairly and with dignity and respect. Staff knew people well and good positive relationships had developed between people and staff. People’s diverse needs were taken into account and reasonable adjustments were made to the way the service was delivered to meet those individual needs.

The premises were safely managed. Recent improvements had been made to the environment to make it more pleasant and homely. Further refurbishment work was planned to replace carpets and improve decoration.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs recorded. Where appropriate, relatives were included in the reviews. Nursing care plans were comprehensive and regularly updated.

Activities were provided by the activity coordinator during weekdays. There was a written and pictorial record of activities which had taken place.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

The service used a variety of methods to assess and monitor the quality of the service. These included regular audits of the service and staff and resident meetings to seek the views of people about the service.

We previously carried out a focused inspection on 30 June 2016. The previous inspection was carried out in response to anonymous concerns that the service was inadequately staffed and people’s needs were not being met. We were not able to substantiate the concerns and found the service was meeting the requirements of the regulations. However, we could not improve the overall rating for the service from 'requires improvement' because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

We carried out this focused inspection on 11 November 2016. This inspection was in response to further anonymous concerns received that the service was not adequately staffed and not always meeting people’s continence needs. It was alleged that there were strong incontinence odours where people were not regularly provided with personal care.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Trengrouse on our website at www.cqc.org.uk

At the time of this inspection the service did not employ sufficient numbers of staff to meet peoples’ needs. However, we found the registered manager had used agency staff appropriately to cover these staff shortages. A targeted recruitment campaign had also been completed which had led to the appointment of eight additional staff. This meant that although the service was short staffed people's care needs had been met and appropriate action taken to address and resolve this issue. The registered manager told us they always ensure the rota was fully covered before leaving the service.

There were seven people who were required to have one to one care from individual staff and all had their own staff member present on the day of this inspection. The staff who covered the one to one shifts were from another agency. Many of these staff had worked at the service for a long period of time and were very familiar with the service and the people who lived there. This meant there was continuity of support for people from familiar faces.

Staff recorded when people were provided with personal care, including pads changes. We reviewed five people’s records and found they had all been provided with regular personal care and pad changes.

We found there were concerns regarding the condition of some parts of the premises. For example, strong incontinence odours pervaded some areas of the service. One bathroom had a broken toilet seat and where the door lock had been removed there was a hole in the bathroom door. Another bathroom was clearly marked with a pictorial sign of a bath, but no longer contained a bath as it had been removed. This bathroom was accessible by people living at the service and contained a bag of soiled laundry, a broken paper towel holder, a chair, a cushion and trailing water pipes. One person’s bedroom had a blocked sink which was full of water. None of these issues had been reported to the manager or the maintenance person. This meant there was not a robust process for staff to report any faults to the maintenance person and such issues were not addressed in a timely manner.

Staff told us they were happy working for the service and felt well supported by the registered manager. There were staff meetings held to seek their views and experiences of the service provided and share information. Staff were provided with supervision and appraisals. The registered manager monitored staff training. This meant that any updates would be provided in a timely manner.

Accidents and incidents were recorded by staff and this information was audited by the registered manager and head office. This meant that any patterns or trends would be identified in a timely manner and action taken to help reduce the risk of any re occurrence.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014.

We previously carried out a comprehensive inspection of Trengrouse on 23 February 2016. At that inspection we identified a breach of the legal requirements. This related to the way the service was being staffed. We issued one requirement and told the provider to take action to address the breach of the regulation. We also found the service was not always effective because there were not enough staff supporting people with their lunchtime meal where they required help. The provider sent the Care Quality Commission an action plan following the publication of the report. We checked to see if the service had made the required improvements identified at that comprehensive inspection.

We carried out this focused inspection in response to anonymous concerns that the service was not adequately staffed to meet people’s needs. This included staff not having time to respond to people’s complex needs. It was also alleged the way staff supported people to move was not safe. People’s continence needs were not being met.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Trengrouse on our website at www.cqc.org.uk

The service is required to have a registered manager and at the time of our inspection a registered manager was 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.

During this inspection we found the way the service was staffed had been reviewed and changes made to shift patterns. Dedicated staff were available in the communal areas of the service during the day to oversee people who may be at risk due to their complex needs. There was a reliance on the use of agency staff. However a recent recruitment drive had employed six care staff. These staff were not yet working in the service as they were currently undergoing checks to ensure they were safe to work with vulnerable people.

Some people displayed needs which challenged others. Where this occurred staff responded in a calm and professional manner. The instances we witnessed resulted in staff managing the situation’s to ensure the person and others were safe. However, not all staff had received formal training in how to manage these situations. The registered manager confirmed this had been recognised and they were currently arranging the training with the organisations training department. The training was planned for in forthcoming months.

Where people required help to move around the service there was a range of suitable equipment to support staff to do this safely. Staff had received training to ensure moving people was carried out using approved techniques. Staff told us, “They (Cornwall Care) make sure we are up to date without moving and handling courses” and “There are times when we have to act immediately to keep the person safe.”

Where pressure mats were being used to monitor people’s movement in their rooms they were all in working order and people who required them had been assessed using ‘Best Interest’ meetings and the service had applied for authorisation under Deprivation of Liberty Safeguard (DoLS).

The design of the service had been improved by making changes to the way seating was provided in lounge areas. This meant people had more choice of where to sit without restricting their movement around the service.

Where people required support to manage their continence needs there were suitable products provided and this was monitored by a named staff member. There were clear records in place demonstrating how people were assessed for help to manage their incontinence. All products were ordered for the person and there was no evidence of continence products prescribed for the person being used for other people.

During the previous inspection of February 2016 we found some people were having a late breakfast followed by lunch in a very short timeframe. During this inspection we found action had been taken to address this by informing kitchen staff of late breakfasts so that they knew the person may not want lunch at the time it was served and accommodated this by providing a later lunch if necessary. Where people required support to eat their meals they were being supported by enough staff to ensure there was one to one support. This was an improvement from the previous inspection when some people were left with their meals in front of them without suitable assistance.

Trengrouse is a care home which provides accommodation for up to 41 people who require nursing care. At the time of the inspection 37 people were living at the service. Most people who lived at Trengrouse required general nursing care due to illness. Most people were living with dementia. Trengrouse is a purpose built single storey building with a range of aids and adaptation in place to meet the needs of people living there.

The service is required to have a registered manager and at the time of our inspection a registered manager was 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.

Most people had complex needs and were not able to tell us about their experiences. We spent time in areas of the service to observe how people’s needs were being met. There were not enough staff available to support people throughout the morning period. People were not supervised in lounge areas for periods of time. Some people became distressed and were responded to only when staff passed through the lounge. The service had identified the minimum numbers of staff required to meet people’s needs. However the way staff were allocated around the service at lunchtime meant some people had to wait for some time before they received their meal. The service was in the process of recruiting more care staff.

Accidents and incidents were recorded by staff in people’s records. These incidents were regularly audited by the manager and overseen by the organisations clinical lead. Care plans showed that where a risk had been identified there was guidance for staff on how to support people appropriately in order to minimize risk and keep people safe.

People’s care and support needs had been assessed before they moved into the service. They included risk assessments to ensure peoples safety. Care records included details of people’s choices, personal preferences and dislikes.

Staff supported people to be involved in and make decisions about their daily lives. Where people did not have the capacity to make certain decisions the service acted in accordance with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People were protected from the risk of abuse because staff had a good understanding of what might constitute abuse and how to report it. All were confident that any allegations would be fully investigated and action would be taken to make sure people were safe.

Recruitment processes were satisfactory; for example pre-employment checks had been completed to help ensure people’s safety.

The medicines system was well organised, and people received their medicines on time and there were safe systems for storage. People had access to a general practitioner (GP), and other medical professionals including a dentist, chiropodist and an optician. Where referrals for further investigation were made by a GP, staff had made sure records were regularly updated so there was a clear audit trail for any prescribed treatment. A health professional told us the service managed medicine systems well.

The cook had information about people’s dietary needs and special diets. Where necessary staff monitored what people ate to help ensure they stayed healthy. Meals which were required to be service with a soft consistency had food blended together. The presentation was not appealing. The organisation had recognised this and were testing food moulds which would present in a more appetizing way

Staff were positive about their work and confirmed they were supported by the management team. Staff received regular training to make sure they had the skills and knowledge to meet people’s needs.

The service had developed a range of meaningful activities for people living with dementia. A dedicated activity coordinator provided a range of daily activities for small groups and also therapeutic sessions with people who stayed in their rooms for reasons of illness.

People told us they knew how to complain and would be happy to speak with a manager if they had any concerns. Families and staff felt they could raise any concerns or issues they may have with the manager, who they said was approachable. People felt their views and experiences were listened to.

The management team used a variety of methods to assess and monitor the quality of the service. These included regular audits and meetings with all stakeholders of the service. Response from this monitoring showed that overall satisfaction with the service was very positive.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.

The inspection team consisted of two inspectors. We observed care and support, looked at care plan records and also observed staffing levels within the home. We looked at systems in place to support staff and also the quality monitoring systems the provider had in place. We spoke with the registered manager and deputy manager as well as a number of nurses and care staff working in the home. In addition we observed interaction between staff and people living at Trengrouse as well as speaking with some of the people using the service. Some of the communication with people was limited, due to their individual levels of dementia as well as other cognitive disorders.

Information we gathered during the inspection helped answer our five questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

Is the service Safe?

We looked at staffing levels in the home to ensure they were safe to meet the needs of people living there. We saw there were both nurses and carers on duty providing nursing care and support to people living there. Staff told us that it is a busy home and there were times when they felt under pressure, however they all told us that it was a job they liked and generally there were enough staff in place to meet the needs of people using the service.

Is the service effective?

We looked at records relating to the care and welfare of three people living at Trengrouse. We did this to evaluate how people’s continence needs were being met and managed. This was due to concerns being expressed that the continence management system was not supporting people effectively. We found there were adequate continence products available for the assessed needs of individuals. We identified an occasion when an order had recently been missed resulting in the manager requesting additional supplies from other services for a brief period. The responsibility for ordering the products in a timely manner had now been delegated to individual staff members and would be audited by the management team to ensure its consistency.

Is the service caring?

We spent time in communal areas around the home to observe how staff were responding to people’s needs. We saw staff taking time to sit with people. In one instance a member of staff spent time assisting a resident to eat their lunch. We observed they did this in a sensitive manner by sitting with them, talking with them throughout and ensuring they took their meal in the persons own time. The staff member told us, “This is what I like doing spending time with residents, it’s the best way to get to know them”.

Some people required one to one care. This meant a designated member of staff is with the person for a specified number of hours as contracted by other health agencies. We saw staff with people receiving one to one care and support. Staff were patient and sensitive to their needs. One comment included, “One to one’s are hard but very rewarding”. Another staff member told us, “It is a challenging job at times but I really like this work it’s so rewarding”.

Is the service responsive?

The service worked with other agencies including social services and other healthcare professionals to make sure people received care and support in a consistent way. This meant people received the right care and support to meet their individual needs and remain as independent as possible.

Is the service well led?

The service had a registered manager and deputy manager in day to day control of the home. In addition the organisation, Cornwall Care provided senior management support. This meant there were systems in place to monitor the service.

Staff told us that in general they were clear about their roles and responsibilities. This helped to ensure people received a good quality service at all times. However not all staff felt their role and responsibility was always recognised by the management team. The management team told us they had systems in place including supervision at all levels and staff meetings, for individual staff groups to ensure all staff felt valued. However they accepted there might be occasions when some staff were not satisfied with the support available and would take this information back to the senior management team.

We saw evidence of staff at all levels having the opportunity to attend regular meetings. These meetings were minuted and we saw examples of staff receiving clear direction and being informed of changes occurring in the service. This meant staff had the information they required to carry out their individual roles and participate in the service development.

We saw care plans directed staff as to the care and support people needed. We saw risk-assessments and assessment tools were in use and reviewed. Activities were routinely available and care records described people’s lifestyle at Trengrouse, although there was room for improvement. We were told some people enjoyed trips out in the home’s minibus, and we saw photographs of recent activities.

There were enough staff on duty to provide personalised care that met people’s preferences.

Records were up to date, accurate and stored securely.

We saw people were spoken with in an adult, attentive, respectful, and caring way. People talked with staff during personal care and when being assisted. We saw people assisted by staff and equipment being used properly, for example, wheelchairs with footrests in place.

We saw care plans were inconsistent in the detail provided and did not always direct staff as to the care and support people needed. We saw risk-assessments and assessment tools were not always reviewed.

Activities were not routinely available and care records did not describe people’s lifestyle at Trengrouse. We were told some people enjoyed trips out in the home’s minibus.

Trengrouse adhered to robust recruitment practices in order to protect people.

There were not enough staff on duty to provide personalised care that met people’s preferences.

Staff were supported in their work with training and supervision.

During our inspection, we found people's privacy dignity and independence were mostly respected. People's views and experiences were not always taken into account in the way the service was provided and delivered in relation to their care.

People were protected from abuse and staff were trained and supported to carry out their roles.

The home was clean and the staff followed infection control guidelines.

Medicines were administered safely and staff were guided by the homes medicines policy and procedure.