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Inspection Summary

Overall summary & rating


Updated 7 July 2016

We carried out this unannounced inspection of Trevarna on 24 May and 7 June 2016. The previous focused inspection in January 2016 found there was a breach of regulations. This was because the service did not always have the necessary information to accurately monitor people’s nutrition and hydration. At this inspection we found improvements had been made in this area and the service was now meeting the relevant requirements’.

Trevarna is a care home with nursing that provides residential care for up to 53 people. At the time of the inspection there were 49 people using the service. Most people who lived at Trevarna required general nursing care due to illness. Most people also had dementia, physical or sensory disabilities. .

The service is required to have a registered manager and at the time of our inspection a manager was progressing through the registration process. 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 had reviewed and made changes to ensure monitoring of people’s nutrition and hydration had improved. People were offered a choice of healthy and nutritious meals and staff were familiar with people’s specific likes and dislikes. The cook had information about people’s dietary needs and special diets. Staff supported people to eat meals where they needed help.

Systems were in place to record safeguarding concerns, accidents and incidents and take necessary action as required. Staff had received safeguarding training and understood their responsibilities to report any unsafe care or abusive practices.

Procedures were in place to ensure medicines were managed safely. Staff responsible for the administration of medicines had received training to ensure they had the competency and skills required. Additional training had been delivered to senior care staff to support nurses when administering medicines. Medicines were safely kept and appropriate arrangements for storing were in place.

The service had reviewed the way it was staffed and had made changes to increase staffing levels at the busiest times of the day. This ensured there were enough staff on duty to respond to people’s needs.

Staff working at the service understood the needs of people they supported so they could respond to them effectively. Staff had been trained and had the skills and knowledge to provide support to the people they cared for. One staff member told us, “The training is really good here. I get reminded when my training needs updating.”

The manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). This meant they were working within the law to support people who may lack capacity to make their own decisions.

Visitors reported good relationships with the staff and that the management team were approachable. Families told us, “They (staff) are so patient and caring, we couldn’t ask for better care for (person’s name)” and “I visit a lot and am always made to feel welcome.”

Staff recruitment files contained the relevant recruitment checks, to show staff were suitable and safe to work in a care environment, including Disclosure and Barring Service (DBS) checks. The recruitment process took account of the skills and knowledge required, to provide care to meet people’s needs. There were enough skilled and experienced staff to help ensure the safety of people who used the service.

People told us they knew how to complain and would be happy to speak with the manager if they had any concerns. One person said, “I am more than confident I would be listened to if I was not happy with anything.”

There were systems in place to assess and monitor the quality of the service. Meetings and surveys had taken place and showed people were engaged with and listened to.

Service certificates were in place to make sure equipment and supply services including electricity, fire systems and gas were kept safe.

Inspection areas



Updated 7 July 2016

The service was safe. Risks associated with medicines management, infection control, cleanliness, and environment factors were assessed and responded to where necessary.

Staffing levels were sufficient with an appropriate skill mix to meet the needs of people who lived at the service.

Recruitment procedures were safe

Staff knew how to recognise and report the signs of abuse. They knew the correct procedures to follow if they thought someone was being abused.



Updated 7 July 2016

The service was effective. People were supported by staff who were sufficiently skilled and experienced to meet their needs.

People had access to healthcare professionals including doctors and healthcare specialists.

Staff supported people to maintain a balanced diet appropriate to their dietary needs and preferences.

The service had policies in place in relation to the Mental Capacity Act 2005 (MCA) and depriving people's liberty, and these were put into practice.



Updated 7 July 2016

The service was caring. Staff were kind and compassionate and treated people with dignity and respect.

People were supported by caring and attentive staff who showed patience and compassion to the people in their care.

Staff respected people’s wishes and provided care and support in line with those wishes.



Updated 7 July 2016

The service was responsive. People received personalised care and support which was responsive to their changing needs.

Activities linked to people's abilities and interests were available.

People knew how to access the complaints process, and who to talk with if they wanted to raise a concern.



Updated 7 July 2016

The service was well led. Systems and procedures were in place to monitor and assess the quality of their service.

Staff worked in partnership with other professionals to make sure people received appropriate support to meet their needs.

Staff were motivated to develop and provide quality care and told us they felt supported by managers.