Trepassey Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement.

At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The manager promoted a positive learning culture by ensuring lessons learned from incidents, accidents, complaints and safeguarding concerns were routinely shared with staff. Learning was communicated through handovers, memos and team meetings, enabling staff to reflect on practice, improve their knowledge and reduce the risk of similar events occurring. This supported a culture of openness, continuous improvement and accountability.

The management team further strengthened the learning culture through daily walkarounds of the service. These provided opportunities to observe practice, engage with people and staff, identify areas for improvement and recognise good practice. Any concerns identified were addressed promptly, and actions were monitored to ensure improvements were implemented and sustained. This approach helped promote continuous learning and drive positive outcomes for people using the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People experienced coordinated care through effective partnership working with health and social care professionals, including GPs, district nurses and therapists. Professional advice was recorded and reflected in care plans, helping staff provide safe, consistent and person-centred support.

Information was shared appropriately to support continuity of care and safe transitions between services. Staff monitored people's health and wellbeing, responding promptly to changes by seeking professional advice and support when needed. Family members told us they were promptly informed of any changes to their relative’s health or wellbeing. Comments included, “The staff are alert to any changes”, “If [Name] is a bit off colour, they are very good at responding quickly” and “I am told if there are any skin tears or bruises, they are very open and quick to respond to any situation.”

This collaborative approach ensured people's changing needs were recognised and responded to effectively, promoting positive outcomes. Family members told us they were kept informed of significant changes and involved in discussions about people's ongoing care where appropriate.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were protected from abuse and avoidable harm. People told us they felt safe, and family members confirmed they had confidence in the care provided.

Staff understood their safeguarding responsibilities and were able to describe how they would recognise and respond to concerns. Safeguarding processes were in place, and records showed concerns were reported appropriately and acted upon when required. Staff worked alongside local authorities and other agencies to help ensure people received the support and protection they needed.

Accidents and incidents were reviewed to identify learning and reduce the risk of recurrence. All staff had completed safeguarding training and received annual refresher updates.

The manager maintained oversight of people's capacity assessments and Deprivation of Liberty Safeguards (DoLS) authorisations. Where required, applications and renewals had been submitted appropriately to ensure people were deprived of their liberty only when this was lawful, necessary and in their best interests. This helped to protect people's rights while ensuring they received safe and appropriate care.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and their family members were involved in decisions about managing risks associated with their care and support. Risk assessments reflected people's individual needs, preferences and abilities, helping staff to balance safety with choice and independence. Staff knew people well and understood how to manage risks, supporting people to make informed choices, participate in meaningful activities and access the community where appropriate.

Equipment and monitoring systems were used with people's consent to help keep them safe. For example, bed sensors alerted staff when people at risk of falls got out of bed, enabling a timely response while maintaining their dignity and independence. Risk assessments were regularly reviewed and adapted in response to changes in people's needs, helping to ensure people received safe, personalised care and support that promoted positive outcomes.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People lived in a safe, clean and well-maintained environment. Systems were in place to identify, assess and manage environmental risks, helping to protect people from avoidable harm. Routine checks of the premises and equipment were completed to monitor safety and ensure the environment remained suitable for people's needs.

The provider maintained key safety systems, including up-to-date gas and electrical safety certification. Fire safety arrangements were robust, with regular fire drills and routine checks of fire safety equipment.

People had Personal Emergency Evacuation Plans (PEEPs) which provided staff with clear guidance on how to support them safely in the event of an emergency. Staff understood these arrangements and their responsibilities for keeping people safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were supported by enough staff who had the skills, knowledge and experience to meet their needs safely and effectively. Staff were visible throughout the home and responded promptly to people's requests for support. People and family members spoke positively about the staff team and told us they were confident in their ability to provide safe care. We received mixed feedback from family members in relation to staffing. Two family members commented that there did not always seem to be enough staff and that there were less staff now than there used to be. During our visits we found there were ample staff to meet people’s needs in a timely manner.

Safe recruitment processes were followed to help ensure staff were suitable for their roles. Appropriate pre-employment checks, including DBS checks and references, were completed before staff started work.

Staff received training, supervision and ongoing support to maintain their skills and competence. They told us supervision sessions were valuable opportunities to discuss their practice, people's needs and their professional development. Staff comments included, “We all work well together and get on together as a team”, “I have had ample training to learn my role” and “I am being supported to undertake my NVQ level 2.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected from the risk of infection by effective infection prevention and control practices. People and family members consistently told us the home was clean, well maintained and free from unpleasant odours. One family member said, “[Name's] room is spotless and always smells very clean. I have never smelled unpleasant odours in the home.” Another family member stated, “The care home is very beautiful. It is spotlessly clean and Mums room is deep cleaned regularly.” Our observations during the assessment confirmed people's bedrooms and communal areas were clean, tidy and free from clutter.

Staff followed infection prevention and control procedures and used personal protective equipment (PPE) appropriately to help reduce the risk of cross infection. Systems were in place to monitor infection prevention and control practices, including regular audits and oversight processes. These were supported by clear policies and procedures which reflected current best practice guidance and helped ensure risks were effectively identified and managed.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and as prescribed. People told us staff supported them effectively with their medicines, and records confirmed medicines were administered at the correct times. One person said, “The staff always make sure I get my medicines on time.”

Medicines were stored securely, and stock checks were accurate, helping to ensure medicines were available when needed. Electronic medicine administration records (MARs) supported safe practice by preventing medicines from being recorded as administered before the required interval between doses had elapsed.

Where people were prescribed medicines on an 'as required' basis, clear protocols were in place to guide staff on when these should be administered. Staff received training and regular competency assessments to ensure they administered medicines safely. Where errors occurred, appropriate action was taken, including additional competency checks and support.

Systems were in place to monitor the safety of medicines management. Regular audits, alongside reviews of missed medicines and stock levels, helped identify concerns promptly and supported continuous improvement to ensure people received their medicines safely and in accordance with their prescriptions.