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Archived: Trefula House Inadequate

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Inspection Summary

Overall summary & rating


Updated 24 October 2020

About the service:

Trefula is a care home that provides personal and nursing care for up to 44 people, all who are living with dementia, and / or have other mental health issues. At the time of the inspection 41 people lived at the service. All of the people lived there permanently. The service primarily caters for people aged 65 and over, although at the time of the inspection some younger people were accommodated. The service was divided into two restricted units; ‘St Mawes’ / ‘Restormel’, and ‘Pendennis’ / ‘Carn Brea’. Pendennis / Carn Brea provided a higher emphasis on general nursing care. Both accommodated people with dementia and/or other mental health care needs.

People’s experience of using this service:

¿ Steps taken to minimise the risk of unwelcome visitors going into other people’s bedrooms were not always effective. This caused some people anxiety. Suitable steps were not taken to safeguard people.

¿ Risk assessment processes were not always safe for example, in the case of specific individual’s: regard to the use of bedrails, emergency evacuation plans in the case of a fire; pressure sore prevention.

¿The lack of suitable recruitment checks put people at risk from staff who were not fit to work with vulnerable people. Staffing levels and deployment was not always sufficient to meet people’s needs.

¿ Medicines were not always managed safely. The management of external preparations, such as creams and lotions, was not effective. The service did not have an effective audit system. People’s medicines such as skin patches were not always managed safely. The gaps between medicine rounds were often not satisfactory which could result in medicines being given too closely together.

¿ Infection control procedures were not always effective. For example, we had concerns about the storage of some infection control products, and the cleanliness of some areas within the service.

¿ Assessment processes, before people came to live at the service, were not always satisfactory, and led to the service agreeing to admit some people who were not suitable to live there.

¿ Staff induction, training, supervision and appraisal systems were not always satisfactory. This meant staff were not always equipped with the right skills, knowledge and support.

¿ People did not always receive the correct support with eating and drinking. For example, this put some people at risk of choking. Records kept were not always sufficient.

¿ Health care records were not always comprehensive and did not detail what treatment people had received, or when this was next required.

¿ People’s rights were not always maintained in line with the Mental Capacity Act 2005. For example, when conditions were applied to Deprivation of Liberty Safeguard agreements, there was not always sufficient evidence these were being met. Staff training and knowledge about the Mental Capacity Act 2005 was not always effective.

¿ People did not always have access to a call point to summon staff in emergency

¿ People did not always have regular opportunity to have a bath or a shower.

¿ Care planning and guidance for staff to provide good quality care was not always satisfactory. Care plans were not always reviewed regularly and therefore were inaccurate.

¿ There were not sufficient planned activities available to people on a regular basis.

¿ End of Life care planning was not satisfactory and did not give staff guidance about people’s wishes and needs.

¿ Management was not effective, and had not provided person centred high quality care.

¿ Governance arrangements were not satisfactory. For example, there were inadequate audit and quality assurance arrangements to assess service quality, and bring about improvements when required.

¿ People said they liked the food, were provided with a choice, and were offered regular drinks.

¿ People said they liked the staff, and staff were kind and respectful.

¿ Staff said training was good, and they had received comprehens

Inspection areas



Updated 24 October 2020

The service was not safe.

Details are in our Safe findings below.



Updated 24 October 2020

The service was not effective

Details are in our Effective findings below.


Requires improvement

Updated 24 October 2020

The service was not always caring

Details are in our Caring findings below.


Requires improvement

Updated 24 October 2020

The service was not always responsive

Details are in our Responsive findings below.



Updated 24 October 2020

The service was not well-led.

Details are in our Well-Led findings below.