Archived: Treseder House

We found the following examples of good practice.

Staff and the registered manager were using personal protective equipment (PPE) correctly and current infection prevention and control guidance was being followed. Training in the use of PPE, infection control practices and Covid-19 had been provided and regularly updated. Hand wash facilities, PPE and infection control guidance was readily available throughout the service.

The service has good stocks of PPE and additional equipment was available for use by staff in the event of an outbreak of the infection. The registered manager had been trained in the fitting of higher specification face masks and there were appropriate procedures in place for the management of risks associated with aerosol generating procedures.

The registered manager routinely worked alongside care staff and provided informal training to ensure current infection control guidance was fully understood and followed. On the day of our inspection, a visiting contractor failed to comply with the services infection control policies. This behaviour was promptly challenged and resolved by the registered manager.

The service was clean, clutter free and reasonably maintained. A water leak had resulted in damage to the service’s wet room celling. Repairs were planned but had been delayed as a result of the national lockdown.

Increased cleaning activities had been introduced within the service. All high contact areas were regularly cleaned during the day with additional cleaning tasks being completed by night staff.

The service was currently closed to most visitors as there was a national lock down in place. Previously, arrangements had been made to enable relatives to visit the service safely and a screen had been purchased to facilitate socially distanced visiting. People understood the necessity of the current restrictions and were able to exercise in the community independently or with support from staff. Video conferencing technologies had been used successfully to enable people to maintain relationships which were important to them.

The service had appropriate admissions systems in place to ensure people’s safety. Everyone who was admitted to the service, or returned to the service following a hospital admission, was initially supported in isolation. Regular testing of staff and people who used the service was completed in accordance with current guidance. Arrangements had been made to enable people and staff to access the vaccine.

Plans had been developed detailing how an outbreak of the infection would be managed, and the services’ infection control policies and procedures had been reviewed and updated in response to the pandemic.

The registered manager had maintained good communication links with people, relatives and staff to ensure everyone understood why the current precautions were necessary.

People’s experience of using this service: During the inspection in April 2018 we found some areas of the service were not meeting regulations. This included maintenance of the environment, lack of mental capacity assessments and lack of oversight in some areas of governance of the service. During this inspection we found the service had made improvements in all areas and met with regulations.

Risks of abuse to people were minimised because staff demonstrated a good awareness of each person's safety needs and how to minimise risks of abuse for them. The environment was safe, and regular health and safety checks were carried out.

People were supported by staff who had the skills and knowledge to meet their needs. Staff understood and felt confident in their role. People’s health had improved because staff promoted healthy active lifestyles. They worked in partnership with a range of healthcare professionals and followed their advice.

There was always guidance for staff on how to support people. Staff were able to tell us the support people needed to keep them healthy and safe.

There were systems in place to help ensure staff were up to date with any change in people’s needs and how to respond to them.

People were supported in the least restrictive way possible; the policies, systems and culture in the service supported this practice.

Staff were friendly and spent time talking with people and supporting them in their chosen routines. Some people were able to go out independently and this was encouraged. Other people were more reliant on staff and they had opportunities to go on various trips and attend day services.

People's concerns and complaints were listened and responded to. Accidents, incidents and complaints were used as opportunities to learn and improve the service.

Rating at last inspection: Requires Improvement (Report published 20 June 2018)

Why we inspected: This was a planned inspection based on the rating at the last inspection. At this inspection, the service had made improvements and rated Good overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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

Treseder House is a ‘care home’ that provides care for a maximum of eight adults with learning and/or physical disabilities. The service is owned and operated by the Royal Mencap Society. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is owned and operated by the Royal Mencap Society and can accommodate a maximum of eight people.

At the time of the inspection there were seven people living at the service. The service is set in a detached house on two floors with access to the upper floors via stairs. One room had en-suite facilities; other rooms shared three additional bathrooms, one of which was specially adapted with a hoist to support people with limited mobility. Shared living areas included a lounge, a dining room, a garden with decking area and patio seating area.

The service had undergone a number of management changes in recent months including a new service manager and an interim Area Operations manager.

The service is required to have a registered manager in post to hold responsibility for the day-to-day running of the service. 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. The registered manager had given CQC notice of a period of absence from their position.

Most people living in the service had limited verbal communication and were not able to tell us in depth their views about the care and support they received. However, we observed people were relaxed and comfortable with staff, and they received care and support in a way that kept them safe. People's behaviour and body language showed that they felt cared for and that they mattered. Some people were able to tell us their views and said they felt safe and happy living at Treseder House. It was clear people were comfortable with staff and moved freely around their home.

Support was provided by a consistent staff team who knew people well and understood their needs. Staff were positive about the people they supported and demonstrated a good knowledge of people’s support needs. We saw that staff had good relationships with people and displayed empathy and warmth in their care. Staff comments included, "I believe people have a good life here. We try our best to make them happy" and "The staff seem to be happy and the people we support are happy."

People were encouraged to be individuals and do what they wanted to do to provide them with a fulfilling life. For example, people who could, went out regularly to local community activities, such as day placements. People also left the service for trips supported by staff. There were a range of personalised and appropriate risk assessments in place to help keep people safe.

There were enough staff to meet people’s changing needs and wishes. Staff said they felt supported by managers and received regular individual supervision. There were also regular staff meetings which gave staff the chance to meet together as a staff team to discuss people’s needs and new developments for the service.

The atmosphere at the service was calm and happy. During the inspection we saw people were well supported and took part in their planned activities for the day. This included attending various community activities and day placements. People told us they enjoyed these activities.

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Relatives were positive in their feedback about the service. We were told people were welcome to visit and the service was, “very caring.” Comments from relatives included, “My [relative] has been at Treseder House for many years. The staff I've found very considerate for the needs of [person’s name], the place has an air of serenity which [person’s name] needs. When I've visited, it’s been easy to talk to the staff. I'm in e-mail contact with the manager. I am contacted if there is a problem."

People were supported to maintain good health, have access to healthcare services and received continuing healthcare support. Staff supported people to eat and drink enough and maintain a balanced diet. People who required it had specialist speech and language assessments and risk management plans in place.

Medicines management systems demonstrated generally safe practice. However, we saw incidents where handwritten additions to people’s medicine administration records (MAR) had not been double signed. This is good practice as it acts as a check to ensure accurate transcription of additional medicines onto medicine recording systems. Management confirmed this was an oversight and the need to ensure this was completed would be highlighted to staff.

The premises were generally well maintained and provided a bright and inviting environment. However, there were some required maintenance issues at the service. For example we saw a kitchen cupboard and plinth were missing in the kitchen. A piece of furniture had been moved from the top of the stairs leaving the wall behind it a different colour from the remaining wall. A bathroom and an upstairs toilet had a strong malodour and a ceiling mounted ventilation extraction unit was unhygienic.

We spoke with the service management about this and were told they were aware of the required maintenance issues. Following the inspection we were sent evidence demonstrating that maintenance requests had been recorded. This demonstrated that the service had made maintenance requests over six months ago including work required in the kitchen which had not been undertaken.

The service had satisfactory safeguarding policies and procedures. Staff were trained to recognise abuse, and what to do if they suspected abuse was occurring. Suitable risk assessment procedures were in place, and risk assessments were regularly reviewed.

The service operated safe recruitment checks for new staff including Disclosure and Barring Service checks (DBS) and reference checks. However, we found the service policy to renew staff DBS checks every three years in line with the local authority requirements had not been consistently completed. When this was drawn to the attention of management a required DBS renewal was begun immediately.

Care records were clear, informative to the reader and were up to date. Records were regularly reviewed, and accurately reflected people’s care and support needs. Details of how people wished to be supported were recorded in their care plans and were personal to them and provided clear information to allow staff to give appropriate and effective support. Any identified risks to people’s care and support were appropriately managed.

Care records demonstrated staff shared information effectively with healthcare professionals and involved them appropriately. Healthcare professionals told us, “Communication is good. They keep us well informed of things we need to know” and “If there have been any concerns about the service user, the staff will contact our service for advice.”

Consent to people’s support arrangements was not consistently recorded in care records. This meant it was not clear from documentary evidence if people had been asked and had agreed to their current support arrangements.

We reviewed service arrangements for ensuring that where people did not have the capacity to make certain decisions that the service acted in line with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. We found the service had met the legal requirements to make a Deprivation of Liberty (DoLS) application where it was clear that a person was subject to a specific deprivation of their liberty, such as use of monitoring equipment due to a health condition.

The service had not carried out mental capacity assessments for three people, who management confirmed, were not free to leave the service without supervision. This was because the people had been assessed by another agency as having capacity to understand and consent to their care plan. However, we found no evidence of discussions with people about this, consent to the arrangements or of review having taken place about the on-going supervision.

People and their families were given information about how to complain. Relatives told us when they had brought an issue to the attention of management in the past, it had been managed quickly. People had confidence that they were listened to and their views mattered.

Quality assurance processes were not sufficient to adequately pick up and address shortfalls in service provision. For example, we found identified maintenance issues had not been addressed in a timely way.

We found breaches 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.

On the day of the inspection there were eight people using the service. The service was last inspected in March 2015 when we found there were two breaches of regulations under the domains of safe and well-led. We received an action plan from the provider about what action the service would take to correct the breaches.

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.

People and their relatives told us they were happy with the care and support provided by staff at Treseder House and believed it was a safe environment. One relative said, “We couldn’t be happier with how Treseder cares for (person’s name). We feel fortunate that (persons’ name) has been able to make a home here and this is their home”. A person who lived at the service told us they felt happy living at Treseder House and it was clear people were comfortable with staff and moved freely around their home.

Staff had made positive relationships with people and understood their needs well. People were encouraged to be individuals and do what they wanted to do to provide them with a fulfilling life. For example, those people who could, went out daily to local community activities, such as voluntary work. People also left the home for trips supported by staff. There were a range of personalised and appropriate risk assessments in place to help keep people safe.

The safety of the premises was looked after by the registered manager, who employed a maintenance person to make sure regular maintenance of equipment such as electrical and gas appliances was carried out. This meant the management of the service had done appropriate checks to keep people safe while they were living at Treseder House.

Staff showed by their actions and by explanation that they understood how to keep people safe, including what they should do if a safeguarding issue was raised. Accidents and incidents were recorded and investigated. This meant management could look for patterns in accidents and incidents and take action to reduce these.

Support was provided by staff who knew people well and understood their needs. There were enough staff to meet people’s changing needs and wishes. The service used a care agency to supply more staff at short notice when needed.

Medicines were stored, handled and recorded safely. This meant that people using the service were given the correct medicines at the correct time and this was clearly recorded.

People who lived at Treseder House and relatives we spoke with, said they were confident in the staff group, and that they provided good quality care. Staff demonstrated they were skilled and knowledgeable about their roles. We were told there were opportunities for further training and to obtaining additional qualifications. Staff said they felt supported by management and received regular individual supervision, and appraisal to review their work performance over the year.

Premises were properly maintained with a clean, bright and inviting environment. All living areas were clean and well looked after. During the last inspection we found the area outside the service had some pieces of old furniture left in the garden instead of having been disposed of. At this inspection we saw the garden and grounds around the service had been cleared and were well maintained.

People were supported to maintain good health, have access to healthcare services and received continuing healthcare support. Staff supported people to eat and drink enough and maintain a balanced diet.

Care records were clear, informative to the reader and were up to date. Records were regularly reviewed, and accurately reflected people’s care and support needs. Details of how people wished to be supported were recorded in their care plans and were personal to them and provided clear information to allow staff to give appropriate and effective support. Any identified risks to people’s care and support were appropriately managed.

Consent to people’s support arrangements was recorded in care records. This meant people had been asked and had agreed to their current support arrangements. Staff consistently asked for people’s consent before assisting them with any care or support. People were involved in making choices about how they wanted to live their life and spend their time. Where people did not have the capacity to make certain decisions the service acted in line with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People and their families were given information about how to complain. Relatives told us when they had brought an issue to the attention of management in the past, it had been managed quickly. People had confidence that they were listened to and their views mattered.

There was a management structure in the service which provided clear lines of responsibility and accountability. There was a positive culture in the service, the management team provided strong leadership and led by example. Management were visible in the service and regularly checked if people were happy and safe living at Treseder House.

There were quality assurance systems in place to make sure that areas for improvement were identified and addressed.These included using quality assurance questionnaires to gather people’s views about the service, and audit processes to check that procedures were carried out consistently and to a good standard.

In June 2014, the Care Quality Commission issued three compliance actions to the registered persons regarding Regulation 17, respect and involvement of people who live at Treseder House, Regulation 10 how effective the provider's assessment and quality of the service is and Regulation 20 regarding records kept by the provider.

This inspection was completed to check suitable action had been taken to improve compliance in these three areas. As part of this inspection we also reviewed the policy and processes involved in supporting staff.

During the inspection we were able to speak with four people who used the service. We also spoke with four care staff who worked at the home.

Below is a summary of what we found.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

On the day of inspection, we judged the service was safe. The service had addressed the identified areas of non-compliance following the inspection in June. People were provided with feedback opportunities in the form of house meetings, clear complaint procedures and an annual satisfaction survey to allow people to input into the running of the service. However, we did have some concerns about the implementation and recording of staff supervision and appraisal systems which had the potential to negatively impact on the care of people supported at the service.

Is the service effective?

On the day of inspection we judged the service was ineffective. This was primarily because of lack of audit and staff follow-up where medication errors had occurred.

We did find positive changes had been implemented to the care/support plans for people who lived at Treseder Lodge. Improved systems had been implemented to monitor people and ensure people were protected against the risk of inappropriate or unsafe care.

The service had a quality assurance policy and procedure. However, we were unable to review how effective the procedure was as we could not access the quality assurance returns for the three month period which pre-dated the inspection. Staff told us monitoring procedures for following up on medication errors were not consistently implemented and a review of associated reporting documentation confirmed this.

Is the service caring?

On the day of inspection we concluded the service was caring. People told us they were 'happy' living at Treseder House. We saw people were treated with respect and care at all times. We saw many examples of positive interactions throughout the day of inspection.

Care records, were up to date and accurately recorded the current situation for each person who lived at the home. There were accurate risk assessments in place to ensure risks were identified and minimised. These were regularly reviewed and staff demonstrated a good level of knowledge about the people they supported.

Is the service responsive?

On the day of inspection we found the service was responsive. We saw clear documentation on care/support plans which demonstrated that when required the service worked effectively with other multi-disciplinary professionals and families to ensure decisions were made in a person's best interests. Significant work had been undertaken by Royal Mencap's quality control staff to update records, minimise duplication of records and highlight significant risk where identified, to protect people effectively.

Is the service well led?

On the day of the inspection, based on the evidence we looked at and the responses from people we spoke with, we concluded the service was not well led. This was primarily because quality assurance records did not agree with staff supervision records. Quality assurance information was unavailable on the day of inspection due to the service manager not being at the service and the deputising manager being unable to access quality monitoring information from the computer system. In addition, it was found that following two recorded medication errors, Royal Mencap's procedure for such incidents had not been followed .

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We judged the service was safe on the day of inspection.

We spoke with people who lived at the home, spoke with the registered manager and three staff. We also examined key documentation such as care plans, risk assessments and daily records. People told us they felt safe and secure. The people we spoke with were positive about the staff who worked with them.

During our last inspection we saw incidents where vital safety information about a person's risk of choking had not been adequately recorded or monitored to ensure the safety of the person. We saw there were now new risk assessments and care plans in place in relation to a number of individuals who were deemed to be at risk of choking.

We saw prominent risk information displayed at the front of care plans which underlined the risk and signposted where further information could be found. We spoke with staff, who were clear about exactly what they should do to safely support each person in the event of a choking event. Staff were required to read and sign their understanding of the contents of risk assessments and care plans in order to demonstrate their understanding of the action required in the event of an emergency.

Is the service caring?

We judged the service was caring on the day of inspection.

We observed kind and patient interactions between staff and the people who were supported. We found care planning did reflect the current needs of people who lived at the home.

Is the service responsive?

We judged the service was responsive on the day of inspection.

We saw evidence that the service had implemented new recording practices and procedures to ensure the care and safety of people who lived at Treseder House.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We judged the service was unsafe in certain key respects.

We spoke with people who lived at the home, spoke with the registered manager and five staff. We also examined key documentation such as care plans, risk assessments and daily records. People told us they felt safe and secure. The people we spoke with were positive about the staff who worked with them. However, we saw there were incidents where vital safety information about a person's risk of choking had not been adequately recorded or monitored to ensure the safety of the person. We found staff, were unclear about exactly what they should do to safely support the person.

We also observed that one person who needed the assistance of two staff members in order to mobilise from a wheelchair was not able to when required because there was not always two staff members available to assist them.

Is the service effective?

We judged the service was not effective in certain key respects.

Three staff members we spoke with showed uncertainty about the contents of people's' care plans and the required level of care and support to be provided. For example, we discussed one person's history of self-medicating which had been stopped following their move to Treseder House. One staff member had no knowledge that the person had ever self-medicated and told us she had no recollection of there being a discussion about the appropriateness of stopping this.

People all had an individual care plan, which set out their care needs. Care plans contained satisfactory information and were accessible to staff. People said staff met their needs and responded promptly when they needed assistance. People said they had access to doctors, community psychiatric nurses, psychiatrists, chiropodists and opticians. However some improvement was required so some professional appointments were more accurately recorded. This would ensure it was easier to find out when some people last received treatment from, for example a dentist or an optician.

Is the service caring?

We judged the service was not caring in certain respects.

We observed kind and patient interactions between staff and the people who were supported.

We found care planning did not reflect the current needs of people who lived at the home and may have increased the risk of significant harm.

Is the service responsive?

We judged the service overall was not responsive.

We did not see evidence that assessments for capacity to consent to medical treatment were undertaken. However, we observed clear documentation that allied professionals such as a GP, had advised that a best interest meeting be carried out in order to meet the physical needs of a person who lived at Treseder House.

Quality assurance surveys had not been completed in line with Mencap's quality assurance policy. Therefore, the opinions of relatives and external professionals such as social services had not been recently taken to further seek to improve the service for the people who lived at Treseder House.

Is the service well-led?

We judged the service was not well-led in certain key respects.

Monthly audits of care and support plans did not identify gaps, omissions and errors.

The number of staff we observed working and on the rotas did not allow people who lived at Treseder House to participate in a variety of activities of their choice. We did not see any evidence that the amount of staff on duty had been considered in line with the actual needs of people supported.

We saw the home was comfortable and clean. We observed each person had individualised their own room to suit their personal taste. People we spoke with told us they were encouraged to choose how they spent their time and had free choice about areas of their life such as when they went to bed and what choice of meals they had. We saw people coming and going from various activities during the day. From our discussions with people who lived at Treseder House, a review of care planning documentation and observations throughout the inspection period we found that people experienced safe and appropriate care and support that met their needs.

We found there were suitable arrangements in place for obtaining, and acting in accordance with, the consent of people who lived at Treseder House in relation to the care and treatment provided for them.

People who lived at the home were safe and their health and welfare needs were met by staff who were appropriately qualified, skilled and experienced.

The provider had appropriate systems in place to regularly assess and monitor the quality of the service.

There was an accessible complaints system in place for identifying, receiving, handling and responding appropriately to complaints.