Archived: Trevarna Residential and Nursing Home

Trevarna is a single storey purpose built service. It is divided into 5 separate areas known as ‘households’, each named after a flower. Each ‘household’ contained an open plan living, kitchenette and dining area with people’s rooms leading off the main connecting corridors. There is a secure central courtyard garden and side garden area. Most rooms have en-suite facilities and there were sufficient numbers of bathrooms and toilets.

In October 2022 Cornwall Care ltd was purchased by Sanctuary Care and is now part of the Sanctuary care group.

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

People, relatives and health and social care professionals spoke positively about the changes made to the service. This had resulted in the standard of care for people improving, staff skills, knowledge and support increasing and relatives feeling more assured that their family members were being cared for safely. Some comments from people and relatives included " I can't fault them”, “I'm happy and family are happy too”, “Its peace of mind that I know he's there and safe” and “I'm completely satisfied with the care [person name] receives” and “I will give them 10 out of 10 with everything.”

The managers of Trevarna spoke positively about the support they had received since the take over of Cornwall Care by Sanctuary care. They acknowledged there had been changes in the service, such as a review of staffing levels, quality audits and changes in systems and processes which had been unsettling for some staff. The changes had been communicated with staff so that they had the opportunity to share their views on the upcoming changes to the service.

Prior to the inspection we had received a concern around staffing levels. Staff varied in their view as to if there were sufficient staff on duty. People and relatives told us they felt there was sufficient staff to meet their family members care needs. The provider had implemented a ‘staffing ladder’ tool which calculated the necessary staffing levels to ensure each person’s health and care needs were met safely. Rotas evidenced that sufficient staff were on duty to meet people’s current needs.

People’s views on the quality of food and drinks were mixed. Our observations of food on the first day of the inspection was not positive. This was feedback to the provider who took immediate action. On our second unannounced visit the food was appetising, and a review of catering services was being undertaken. We have made a recommendation that the provider should seek advice on how to provide choices of food and drink to meet people’s diverse needs, making sure the food and drink they provide is nutritionally balanced and supports people’s health.

The provider had invested in the environment and had a plan of works for future changes to be made at the service. Comments from people, relatives, staff and health and social care professionals were positive about the changes.

The provider had implemented new systems and processes that had improved the standard and quality of the service. For example, systems to assess and monitor the quality and safety of the care provided were more robust and were driving improvement. The service had clear and effective governance systems in place.

The service had an electronic application to record people’s care plans, their risk assessments and people’s daily notes. Care plans were person centred and had detailed information about people’s backgrounds, history, social, physical and mental health needs. Care plans provided information for staff on how to meet people’s identified needs.

People, and their relatives were involved in the development and review of their care plans which detailed their needs and preferences. Staff knew people's care needs well. People were supported to engage in activities.

Staff told us that they had received the training they needed to meet people's needs safely and effectively. Staff were supported in their roles through a plan of supervision. Staff told us they felt supported by the registered manager and her team.

People’s medicines were managed safely. Staff responsible had the necessary skills to administer medicines. Oversight was in place to ensure medicines were managed safely.

There were processes in place to manage infection control risks and there were regular cleaning procedures in place. Visiting was encouraged and their were systems in place to enable relatives to visit safely.

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.

The management team maintained oversight of complaints, accidents and incidents and safeguarding concerns. The management team engaged well with health and social care professionals.

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

Last rating and update

The last rating inspection found that the service was good (published 28 November 2018). We also carried out an infection control inspection in 2022 which did not provide a rating.

At this inspection we have again rated the service as good .

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Recommendations

We have made a recommendation in relation to the provision of food. We will check if the provider has acted on this recommendation at our next inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The management team were continuing to support staff to contain the COVID-19 outbreak at the service. Daily oversight and careful management of staffing levels had meant staff shortages had been managed effectively. Staffing levels were being supported by the use of agency staff and the services own workforce worked additional hours. In recognition of this additional commitment staff are offered a bonus and those working additional hours are paid overtime. The deputy manager said, “It’s important we get the staff on board and they have all worked so hard”.

The service was following current guidance in relation to visiting care homes during outbreaks of COVID-19. Essential care givers and visits to people in receipt of end of life care were possible. However, the service was currently closed to other visitors. People understood the need for these restrictions and were confident staff were taking appropriate steps to manage the outbreak of the infection.

Four relatives we spoke with told us they understood the need for the restrictions in place, and were confident staff were taking appropriate steps to manage the outbreak of the infection. One person was a designated essential care giver. This is a person who can provide companionship, but also additional care and support. They can visit more often and during periods of COVID-19 outbreak. The essential care giver told us, “I am so glad I can help [person’s name] every day with lunch” and “They [staff] are tremendous. A great team”. Other relatives we spoke with told us, “Always keep me informed and up to date,” “Great communication and carers are wonderful,” “I have total peace of mind. They go over and above and during this time they keep us updated on how things are going” and “Staff are excellent”.

The service had a committed staff team to ensure people received care and support in a safe and hygienic environment. People were supported in the service in accordance with national guidance. The staff team supported people and their relatives to understand the policies and procedures surrounding protection against COVID-19.

Additional cleaning protocols were in place to ensure all high touch points were regularly sanitised.

Personal protective equipment (PPE) was available to all staff and visitors. Staff and people living at the service were regularly tested for COVID-19. Visiting was taking place according to current government guidance.

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.

Trevarna is a single storey purpose built service. It is a service divided into five separate domains known as ‘households’, each named after a flower. They all contain an open plan living and dining area with people’s rooms leading off the main connecting corridors. There is a secure central courtyard garden and side garden area. There are fifteen en-suite facilities and there are sufficient numbers of bathrooms and toilets. Some bathing facilities had been modified to support people who had restricted mobility.

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 and associated Regulations about how the service is run.

Since the previous inspection in 2016 the service had developed a model of care specifically designed to promote quality of life outcomes for people living with dementia and a mental health diagnosis.

Without exception families told us the service was the best place for their relatives to live. Comments included, “I know [relatives name] gets the best possible care at Trevarna” and “I have total piece of mind as soon as I leave that [relatives name] is being well looked after. I can stay and that’s made such a difference for us.” A professional told us, “The manager and staff are totally committed to doing their very best for my clients.”

The registered manager was committed to ensure the services management systems were completely effective by completing auditing systems and acting swiftly to address any identified issues. They spoke passionately about their commitment to the development of the service and had oversight of care provision, service quality and everyone's safety.

Since the last inspection staffing levels had been reviewed. In response to feedback and an analysis of incidents an additional shift had been created to make sure people’s needs were being met in a timely manner. Staff were deployed effectively within the service.

Staff completed a thorough recruitment process to ensure they had the necessary skills for their role. Formal systems for supporting care staff were in place.

Risks to people were assessed and actions were identified and implemented to keep people safe. Staff understood people's psychological and emotional needs and appropriate support was provided to meet them.

People had regular access to healthcare professionals and staff worked collaboratively with them.

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

People's medicines were managed and administered in line with best practice and staff had received medicines training and their competency had been assessed.

Staff understanding of ensuring people’s legal rights were protected had improved because staff had been trained and supported by the management team to understand the legal requirements of the Deprivation of Liberty Safeguards (DoLS). Most people lacked the mental capacity to recognise the decline in their physical capabilities, which potentially put them at risk of harm, such as sustaining injuries from falls. These people were subject to restrictive practices or continuous supervision to protect them from the risk of harm and keep them safe. DoLS applications had been made to the local authority to seek the legally required authorisation to have these restrictions in place.

The design of the service meant people living with dementia conditions lived in one of the five independent areas known as ‘households’ depending on the level and effect of dementia they were experiencing. There were three mixed gender households and two single gender households. This was to mitigate risks due to the specific behaviours shown by people who were disinhibited due to their mental health.

In general, the atmosphere was calm and relaxed. People were not restricted in respect of their movement around the area of the household they were living in. People were observed to be spending their time in communal areas or their own rooms. We observed positive and meaningful relationships with staff and staff interacted with people in a caring and respectful manner.

The service used an electronic care planning system. Care plans contained information about the person and what their individual needs were and how they would be met. Care planning was frequently reviewed and people’s changing needs were recorded. Daily notes were completed by staff responsible for people’s care.

There was continuous engagement between the management and all levels of staff through meetings and daily handovers. Staff were supported by senior staff through regular updates. These kept the staff team up to date with any changes and provided any essential information that might be needed to be shared to support peoples care and welfare. Staff told us they felt extremely supported by the management team and senior staff. Staff comments included, “I am so proud to work here and be part of a fantastic team” and “The manager and nurses are very supportive. They are visible as well, not just stuck in the office.”

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.

People were regularly asked for their feedback and regular meetings took place which included relatives to involve them in the running of the service.

There was a complaints policy in place and records showed complaints were responded to in line with this policy.

Staff supported people to eat food that matched their preferences and met their dietary needs. Relatives told us they were made to feel welcome and staff knew what was important to people.

There was a maintenance and refurbishment plan in place to improve the service environment. There was work being carried out in one of the lounge areas. Some areas of the service required attention. This included general decoration and woodwork which was damaged in some areas due to the constant use of equipment. The registered manager assured us this was included in the organisations business plan and would improve.

The environment supported people living with dementia. For example, signage throughout the service showed pictorial images to indicate the rooms function. People had ‘This is me’ information to support staff to get to know the person, their likes and dislikes, hobbies and interests.

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.

The service is divided into five units each individually staffed. Trevarna is a single storey building.

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 CQC 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 and associated Regulations about how the service is run. However, another service manager was deputising in the registered manager’s absence.

We previously carried out a focused inspection of Trevarna on 1 September 2015. At that focused inspection we checked to see if the service had made the required improvements identified at the comprehensive inspection on 10 March 2015. This related to the way the service was staffed. Inspection improvements had been made to the way staff were deployed around the service. However where people required food and fluid monitoring their records were not being maintained to show an accurate record. This resulted in a breach of regulation. The service responded to the breach by providing the commission with an action plan showing what action had been taken to address the breach.

We carried out this focused inspection in response to concerns that the service was not adequately staffed to meet people’s needs. This included staff not having time to complete records and people that required supervision not having the support they required at all times. There were also concerns the manager was not responding to information of concern relayed by staff members.

This report only covers our findings in relation to the ‘Safe’, ‘Effective’ and ‘Well Led’ domains covered in this inspection.You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Trevarna on our website at www.cqc.org.uk

At this focused inspection peoples' fluid and nutrition were being managed had been reviewed and changes put in place to monitor them more effectively. Regular reviews were taking place so that the records were effective and meaningful. However, improvement was still required to ensure all staff were informed of who required monitoring and that the assessed daily amounts of fluid were included in all records, to inform staff and act as a key indicator for them to follow.

There was a deputising manager in post as well as a new deputy manager and they, together with the clinical lead, were continuing to support staff through leadership and operational changes.

People’s health needs were being individually managed and staff had the skills to recognise when people may be a risk of their health deteriorating. People had access to healthcare professionals including GP, chiropodist, dentist and optician.

Staffing levels were continuing to increase and the deployment of staff in each unit had increased since the focused inspection in September 2015. There had been a number of nursing and care staff employed at the service who were currently going through an induction process before commencing work in the service.

There was a current review taking place to introduce a different shift pattern. This would increase staff levels into the evening thereby supporting night staff during the early part of the night shift when some people required more support.

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. Applications had been made for potentially restrictive practice to be authorised, as

appropriate.

Procedures were in place to assess and monitor the quality of the service. Meetings and regular audits were taking place and showed people were engaged in the process.

We identified one breach of the regulations. You can see what action we have told the provider to take at the back of the full version of the report.

Concerns had been received by the Commission that people were being assisted to get up in the morning before they were ready to or chose to.

Is the service safe?

When we inspected this service in June 2014 we found the home was not managing people's continence needs effectively. During that inspection we also found the service had not been managing the hydration needs of some people, by not accurately recording hydration and therefore having the potential to put people at risk. We looked at what action had been taken to address these areas. The service had implemented new records to record and monitor people's food and fluid management and had made the situation safe.

Staff were on duty in numbers that met the basic needs of people living at the home at the time of the inspection. However a current organisation staffing review had identified the need for additional staff to ensure people were safe and receiving care and treatment from staff in numbers to meet the individual needs of the people living at Trevarna.

There had been some restrictive practice in place involving the use of stair gates. This had been used to protect people from disturbance in their rooms by residents with dementia care needs. Whilst this issue had been assessed in a 'best interest' assessment under the Mental Capacity Act 2005, there was no specific evidence of the decision making process as to why restrictive stair gates had needed to be used. Following discussion with the current manager it was agreed the reason for the stair gates was no longer an issue. Since the inspection visit the inspector has been informed of their removal and was told that revised risk assessments were in place for these residents.

When we inspected the home in June 2014 we found a number of breaches in infection control management within the home. We looked at what action had been taken to address these issues. There had been improvement in cleaning schedules. Domestic staff and care staff had clear roles and responsibilities in respect of the cleaning of commodes. The home was seen to be generally clean and free from odours other than a lounge with a heavily stained carpet. This had been noted and addressed by the maintenance team and was to be replaced in the near future.

Staff we spoke with were knowledgeable about infection control and the importance of following current guidelines. A recent inspection of the sluicing facilities by the maintenance coordinator, confirmed additional wash hand basins had been ordered which would provide staff with the necessary facilities to ensure infection control measures were in place.

Is the service effective?

In order to ensure people received access to a range of supporting healthcare services, staff reviewed when health checks were due. People we spoke with told us, 'I see the doctor when I need to. They sort it all out for me'. Also, 'They got my appointment at the hospital organised and made sure I was there in time'.

Improvements in the way people's continence needs were being met and monitored ensured they were effective and changes made where the need was identified.

Improvements to the way infection control measures were being managed ensured they were effective. Necessary equipment was in place including protective clothing and cleaning materials, as well as ensuring staff training in infection control was up to date.

Staff we spoke with had an understanding of people's needs and how to deliver care and treatment for people they were supporting. One staff member told us, 'We are responsible for keeping the information up to date. It's really important because people's needs change so quickly sometimes'.

Is the service caring?

People were treated with respect and dignity by the staff. People told us they felt safe. One person told us, 'Everyone is so kind and helpful'. Another said, 'It's not like home but I feel safe here, there is always someone around for me'.

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People we spoke with told us, 'They are so very patient with me, and it's nice to feel cared for'.

Is the service responsive?

The service worked with other agencies including social services, nurses and healthcare professionals to make sure people received care and support in a coherent 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 inspection in June 2014 identified non- compliance in areas of care and welfare and infection control. This inspection identified what action had been taken by the management team to improve those areas.

Staff did not always feel supported by the management team when concerned about staffing issues. Effective communication with the staff team either through meetings or by other methods would allay concerns relating to changes occurring.

There were a range of audits and systems put in place in by the manager and provider to monitor the quality of the service being provided.

Below is a summary of what we found. The summary is based on information gathered during our inspection which included conversations with people who used the service, relatives, staff and the management of Trevarna.

Is the service effective?

On the day of the inspection we judged the service was effective because all of the people we spoke with who received care from Trevarna were happy with the quality of care they received. People told us 'I am happy here' and the staff are 'marvellous'. We also saw that people's care planning documentation accurately reflected people's medical and psychological needs to enable the home to meet these needs. We saw that staff were aware of peoples' needs and that they delivered the support that they were instructed to.

Is the service caring?

On the day of the inspection we judged the service was caring because people told us their relatives were well cared for by staff. Their comments included 'nothing is too much trouble'. We heard staff talk with the people who lived at Trevarna in a caring manner. In addition we saw staff caring for the people that used the service, including seeing people laughing and joking with staff. We also spoke with two people who were visiting their relative and they told us, 'the attitude towards clients is brilliant' and 'nothing is too much trouble'. One member of staff told us 'It's lovely here, we are like one family'.

Is the service responsive?

On the day of the inspection we judged that the service was not responsive because the physical needs of people who lived at the home were not always being addressed appropriately. Fluid intake, for people at risk of illnesses associated with dehydration, was not documented appropriately and was not being monitored adequately. We also noted that there had been some failures in communication between the care staff and the staff in charge. However we did see that in the vast majority of cases people had been supported to access medical services in a timely fashion and were referred appropriately if a person's needs changed.

In addition infection control procedures and practices were not addressing the present cleansing of commode pots practice in the home. Therefore the home was not ensuring that both the staff, and the people that lived at Trevarna, were adequately protected against the associated risks.

As part of our inspection we spoke with the deputy manager, clinical deputy manager (lead nurse), care staff and laundry staff. Since our previous inspection of Trevarna the home had been working to make improvements to become compliant with the Essential Standards of Quality and Safety.

During our inspection we observed staff were kind and empathetic towards people, and spoke to them in an adult to adult and respectful manner.

Procedures had been and were being put in place to improve and protect peoples' privacy and dignity.

Care plans were detailed and we saw they were updated in line with the information in care reviews. Work was underway to further improve recording standards.

We saw staff were busy and they told us they were currently meeting people's physical and care needs. We saw that seven additional staff had been employed. This was so time could be allocated to meet peoples' emotional and social needs.

We did not speak to people who used the service due to their various health needs.

During our inspection we observed staff were kind and empathetic towards people, and spoke to them in an adult to adult and respectful manner.

Peoples' privacy and dignity was not always protected.

Care plans were detailed, but sometimes we saw they were not updated in line with the information in care reviews.

We saw staff were busy and they told us they were currently managing to meet people's physical needs. However they did not always have time to meet peoples emotional and social needs.

Staff we spoke with said they felt well supported by management.

We spoke to three people who lived at Trevarna and all the comments we received were positive. One person told us, 'I am happy here, they look after me and meet my needs'. Another person told us, 'The food is good and the staff are friendly'.

We spoke to two relatives of people that lived at Trevarna. They told us they were satisfied with the care provided and they were informed of the progress concerning the person they were visiting.

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

Staff told us that training was provided, and also confirmed that staff supervision took place.

Care plans and associated documentation provided sufficient detail to direct and guide staff of the action they needed to take in order to meet people's assessed care needs.

People's records were personalised and provided clear information about the person's wishes and abilities.

Some of the people that lived at Trevarna were unable to tell us about their experiences. We spoke to people who lived at Trevarna and all the comments we received were positive. One person told us, 'I am happy here, they look after me and meet my needs'. Another person told us, ' The food is good and the staff are friendly.

We spoke to a relative of people that lived at Trevarna. They told us they were satisfied with the care provided and they were informed of the progress concerning the person they were visiting.