Trewidden Care Home

People’s experience of using the service:

¿ People were not all able to fully express their views therefore they were not able to tell us verbally about their experience of living at Trewidden. Therefore, we observed the interactions between people and the staff supporting them.

¿ The management team and staff knew people well and understood their likes and preferences and health needs. Staff were caring and spent time chatting with people as they moved around the service. Relatives told us they were welcome at any time and any concerns were listened and responded to.

¿ Staff showed a true fondness for the people they cared for and there was a warm, friendly and welcoming atmosphere. People’s wellbeing was promoted.

¿ The environment lacked appropriate stimulation for people living with dementia. Activities provided were not always meaningful and relevant to people’s backgrounds and interests. We have made recommendations about these issues in the Responsive section of this report.

¿ People were provided with the equipment they had been assessed as needing to meet their needs. For example, pressure relieving mattresses. However, the process for ensuring these mattresses were always set correctly was not robust. We did not evidence any impact on people due to using incorrectly set mattresses. The manager assured us that night staff were going to be asked to sign each night following the checks of these mattresses. We have made a recommendation about this in the Responsive section if this report.

¿ People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

¿ Staff were recruited safely in sufficient numbers to ensure people’s needs were met.

¿ The environment was safe and people had access to equipment where needed. Staff had received appropriate training and support to enable them to carry out their role safely, including the management of medicines.

¿ Quality monitoring systems were in place. However, there was some delay in actioning some audit findings. A recent survey sent out to people and their families had positive responses.

Rating at last inspection: At the last inspection the service was rated as Requires Improvement (report published 1st May 2018) There were no breaches of regulations. However, we were concerned about some aspects of staff support, records kept and support provided to some people by agency staff, staffing deployment and details of people’s lasting powers of attorney were not always clearly recorded. Recommendations were made in the last report due to these concerns. At this inspection the service had made improvements and was rated as Good.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor the service through the information we receive 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

This unannounced comprehensive inspection took place on 27 March 2018. The last inspection took place on 31 January 2017 when the service was not meeting the legal requirements. The service was rated as Requires Improvement at that time. There were some aspects of the premises that required attention, such as re-decoration and carpet replacement. Induction of new staff was not always recorded. Not all staff had received training on the Mental Capacity Act as stated in the service’s policy. The registered manager was not able to take effective action on audit findings due to lack of resources. This meant that identified improvements were not being implemented. Following that inspection an action plan was sent by the provider to CQC stating how they would meet the requirements of the regulations. This inspection was scheduled to review the actions the provider had taken.

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.

The service is required to have a registered manager, and at the time of this inspection there was a manager in post who was in the process of registering with CQC. 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.

We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect. People told us, “I love it here,” “It’s lovely here, the staff are lovely” and “I am very happy.” Relatives told us, “The staff are lovely and caring, some in particular, [person’s name] is treated really well and is always clean and happy when we come,” “Staff seem to know everyone here really well, they know what people like and don’t like, so it feels really personal and homely” and “It’s such a relief knowing that [persons’ name] is well cared for and I can come and visit any time so it is lovely to see [person’s name] looking happy with everyone here.”

The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes. The premises were being maintained. During this inspection there were rooms being renovated and bathrooms updated. However, as noted in our previous report there continued to be tape used to hold down torn/lifted areas of carpeting in places throughout the service. This posed a trip hazard where the tape was lifting in some places. Upstairs carpet was uneven. We were assured this was being addressed with new carpet being laid shortly. Equipment and services used at Trewidden were regularly checked by competent people to ensure they were safe to use.

The service was registered for dementia care, there was some pictorial signage to support people, who were living at the service with dementia, who may require additional support with recognising their surroundings.

Care plans had been recently transferred to an electronic system. Care plans were well organised and contained accurate and up to date information for staff. Some areas of the electronic care planning system were not yet in full use. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff. Risks in relation to people’s daily lives were identified, assessed and most were planned to minimise the risk of harm whilst helping people to be as independent as possible.

The service used a dependency tool and had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had some staff vacancies at the time of this inspection and these posts were being covered by agency staff. The agency staff used were mostly consistent and were very familiar with the service and the people living there. This helped ensure the care and support for people was provided in a consistent manner.

There were systems in place for the management and administration of medicines. It was clear that people had received their medicine as prescribed. Regular medicines audits were being carried out on specific areas of medicines administration and these were effectively identifying if any error occurred such as gaps in medicine administration records (MAR). We saw no gaps in these records.

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. People had access to activities. An activity co-ordinator was in post. On the day of this inspection we saw people enjoying a variety of activities in small groups as well as on a one to one basis.

The use of technology to support effective care delivery was limited. Alarmed locks had recently been fitted to all bedroom doors. This provided the opportunity for people to lock their rooms if they chose. One person’s door was locked at all times to ensure that their room was not accessed by other people uninvited. This had been supported by the person’s family as the person was cared for in bed and unable to call for assistance independently. Staff held the key which was required to open this person’s door.

New staff were supported by a system of induction training and this was recorded. Staff received appropriate training and regular updates. The manager had a record which provided them with an overview of staff training needs. Staff records that we reviewed did not contain evidence of all the one to one supervisions the provider stated had taken place. Staff we spoke with did not recall having regular one to one supervision. However, annual appraisals had been completed by the manager.

Risks in relation to people’s daily life were assessed and planned for to minimise the risk of harm. People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance.

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 was supported by the provider and a recently appointed deputy manger. We had mixed feedback from the staff we spoke with regarding the support they received from the manager. Twenty five staff had left the service in the last year for various reasons. Of 19 care staff working at the service nine had begun working since January 2018. This meant the service was going through a process of change which challenged some staff.

There were effective quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly by both the manager and the provider who visited regularly to support the manager. Audit findings were acted upon and the service was striving to continuously improve the service it provided.

We made some recommendations in this report, that the service seek advice and guidance from a reputable source regarding the regular provision of one to one support to all staff, to standardise the support provided for people by one to one staff and to review how all care and support is consistently recorded. The service was improved from the last inspection and whilst there were no breaches of the regulations we have judged the overall rating of the service remains Requires Improvement due to concerns found.

This unannounced comprehensive inspection took place on 31 January 2017. The last inspection took place on 3 February 2015. There was a breach of the legal requirements at that time regarding the condition of some aspects of the premises. Part of the reason for this inspection was to check on the action taken by the provider to address the concerns raised.

Cornwallis is a care home which offers nursing care and support for up to 51 predominantly older people. At the time of the inspection there were 31 people living at the service. Some of these people were living with dementia. The service occupies a large detached building over three levels, with a passenger lift to provide access for people to the upper floors.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service had registered manager who had been in post since April 2016.

There was concern at the last inspection that some double glazed units were cloudy with condensation and peoples view was obstructed. Also some lounge chairs were badly stained. The service had replaced some double glazed units and also the lounge chairs. However, it was noted at this inspection that some areas of the service required redecoration such as doors, corridors and doorways. Damage appears to have occurred due to the use of wheelchairs through corridors and doorways. The carpet in one corridor had worn through and was taped down. The tape had lifted posing a potential trip hazard to people. Carpets in some communal areas of the service were worn and marked. We were told a new carpet order was in process.

The registered manager was supported by an administrator and the provider. The Cornwallis group had recently appointed a new operations director who supported managers throughout the group and was present at this inspection. However, due to the present recruitment challenges experienced by the service some governance issues were of concern. Some care plans and risk assessments were a little overdue for review. Audit outcomes identified by the registered manager had not been able to be actioned due to time and resource limitations. This meant that identified improvements that were required were not being implemented at the time of this inspection. The operations director and the registered manager told us that the role of the duty nurse and a deputy manager post was being considered so that they could be delegated some of the responsibilities currently being held by the registered manager. We have made a recommendation in the Well led domain that the registered manager is provided with immediate support.

Staff were supported by a system of induction training, supervision and appraisals. Staff confirmed they received an induction when they joined the service. However, there was no record of such an induction being provided to new staff in their files. This meant it was not possible for inspectors to judge what was included in the induction.

People were mostly treated with kindness, compassion and respect. Families and healthcare professionals told us they felt all the staff were kind and provided good care.

There was some additional signage provided throughout the service such as pictorial signs for bathrooms and toilets. This supported people who required extra orientation to their surroundings and supported their independence. We walked around the service which was comfortable and spacious with room for people to move around easily. The service was clean and odour free throughout. The domestic team were well managed and had robust effective cleaning programmes to ensure the service was always clean and tidy.

Systems for the management and administration of medicines were robust. People had received their medicines as prescribed. Regular medicines audits were identifying if errors occurred. However, prescribed creams were not always dated when they had been opened. This meant staff would not know when the item should be disposed of or was no longer safe to use.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. Risks in relation to people’s daily life were assessed and planned for to minimise the risk of harm. Staff received mandatory training relevant for their role. However, training on the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards was not provided to all staff. This training had not been planned for despite the service policy stating that all staff were provided with this training. Some specialised training specific to the needs of people using the service was being provided such as dementia care. Staff meetings were held, which allowed staff to air any concerns or suggestions they had regarding the running of the service. Staff felt supported by the registered manager.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had been using a high number of agency staff to cover both nursing and care shifts for some time prior to this inspection. Two nurses had recently left the service further compounding the shortage of permanent nurses available at the service. Recruitment efforts had received no applicants. The agency staff being used by the service were consistent and those we spoke with had been working for the service regularly for some time providing some continuity to people living at the service.

People's rights were protected because the service acted in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards were applied correctly and any conditions applied to authorisations were being upheld.

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.

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.

People had access to some activities which were provided by the care staff when time allowed. An activity co-ordinator was in not in post at the time of this inspection. However, the recruitment of an activities co-ordinator was in process. People were supported to go out and visit the surrounding area regularly.

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.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

We were able to observe most of the 42 people who used the service. We were not able to converse with them as they had various stages of dementia, the few that we did attempt to talk with seemed very happy in their environment and repeatedly said how lovely all the staff were.

We observed 11 members of staff, the staff we spoke with were happy in their work and had worked at the home for some time, one eleven years, one eight years, one six years. One member of staff said she travelled to work from another town as the manager and staff were good to work with and she enjoyed the challenge of the work.

Is the service safe?

Systems were in place to help the manager and staff team learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. Staff showed a good understanding of the care needs of the people they supported.

Cornwallis alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service. Cornwallis had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DOLS). This helped to ensure that people's rights were protected.

Is the service effective?

People's health and care needs were assessed with them, although people were not involved in writing or reviewing their plans of care. During our inspection it was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people's needs.

Specialist dietary needs had been identified where required. Care plans were up-to-date.

We saw there was good liaison and communication with other professionals and agencies to ensure people's care needs were met.

The quality of recording seen was of a good standard enabling nurses and care staff to use the information correctly.

Is the service caring?

We could not speak with the majority of the people being supported by the service due to their health care needs. We spoke with two people and asked them for their opinions about the staff that supported them. Feedback from people was positive, for example, 'wonderful' and 'Staff are very friendly' and 'Very considerate carers'. When speaking with staff it was clear that they genuinely cared for the people they supported.

People's preferences and interests had been recorded and basic life histories were evident.

Cornwallis had regular support from the local GP practices and other visiting health professionals. This ensured people received appropriate care in a timely way.

Is the service responsive?

Many people who lived at Cornwallis had complex health and care needs and were either not able, or chose not to join in group activities. The care records showed evidence of the lifestyle of these people and we observed that staff spent one-to-one time with people throughout the day.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

The manager told us that regular staff meetings were not held. He said he preferred regular meetings with staff on a one to one basis to disseminate information. This showed the management consulted with staff regularly to gain their views and experiences and improve support for people who lived at the service.

The service had a quality assurance system, and staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.

The people that lived at Cornwallis Nursing Home had a form of dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people had we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allowed us to spend time watching what was happening in a service and helped us to record how people spent their time, the type of support they got and whether they had positive experiences. Some people who lived at Cornwallis Nursing Home were able to tell us about their experience and we also spoke with a visitor and a health professional.

One person who lived at Cornwallis Nursing Home told us, 'wonderful home, well looked after'.

One relative we spoke with on the day of our inspection was complementary about the care and support his X received, they told us, 'The care and attention from carers is exceptional, above average' and 'the food is first class'. However, this relative did tell us that they thought the care home was suffering with staff shortages and told us 'they're a bit short staffed'. We were also told by some staff that they felt there was a shortage of full time nurses to work during the day.

We spoke with the dementia liaison nurse for the home, who told us the manager and staff contacted her appropriately and as necessary for advice and was complementary about the new activities co-ordinator and her enthusiasm for ensuring that she was meeting peoples individual needs.

As part of the inspection we spoke with the manager, nursing staff, care staff and housekeeping staff.

We found, people's privacy, dignity and independence were respected.

Where people did not have the capacity to consent the provider acted in accordance with legal requirements.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

People were cared for in a clean, hygienic environment.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Relatives told us, 'staff are very attentive' and 'they've got patience'. We were told they felt their relatives were safe living at Cornwallis Nursing Home.

We found, people who used the service were not always given appropriate information and support regarding their care or treatment. People's privacy, dignity and independence were not always respected.

People needs were assessed but we found their care and treatment was not planned and delivered in line with their individual care plan. Care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

Where people did not have the capacity to consent the provider did not always act in accordance with legal requirements.

People were not protected from the risk of infection because appropriate guidance had not been followed.

People were not protected against the risks associated with medicine because the provider did not have appropriate arrangements in place to manage medicines.

People were not cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We observed staff interacting with people who use the service in a kind and calm manner. We saw that staff showed, through their actions, conversations and during discussions with us empathy and understanding towards the people they cared for. For example, we saw one member of staff took time to reassure one person when they thought they had lost one of their possessions.

We saw that people's privacy and dignity was respected by the way that staff assisted people with their personal care and knocked and waited for permission (where possible) before entering bedrooms and bathrooms.

We also saw that the care documentation included information about the person's life in a document called 'this is me'. Staff told us that this was helpful in encouraging meaningful activities for the person. We saw that people were given opportunities to take part in activities that they were interested in, for example baking pasties.