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Trefoil House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 4 May 2019

About the service: Trefoil House is a residential care home providing accommodation for older people, who may be living with dementia or a physical disability, who require nursing or personal care. The service is large and split in to four different ‘units’ across two floors. The building has been designed and adapted to support people living with dementia.

People’s experience of using this service: People were not always supported from the risk of harm and abuse as unexplained bruises or injuries were not always investigated thoroughly or referred to relevant professionals.

We observed that people were not always treated with respect and dignity. People’s privacy was not always respected and it was unclear if actions were being taken to address this.

The new manager and area manager were in the process of improving the service, however, more time was needed to fully imbed improvements and changes in culture.

People and their relatives were complimentary about the care they received. People received care that was personalised based on their needs and preferences.

Relatives were very positive about the care that people received at the end of their life.

People were supported with their medicines safely.

The service was clean and well maintained. People had access to areas that were designed as community activities such as a pub and a café.

Staff were well trained and received regular supervision and competency checks to ensure that they had the right skills for their job roles.

Meal times were a sociable experience and people were positive about the choice, amount and quality of the meals.

People were supported to see health professionals to ensure that they lived healthy lives and had good health outcomes.

Complaints were dealt with promptly and to complainants satisfaction.

There were a number of audits completed at different management levels to monitor the quality of the service.

People, relatives and staff were all positive about the new manager and area manager at the service and the impact that they were having.

The new manager was passionate about continuing to improve the service.

We identified a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to safeguarding people from harm or abuse. Details of action we have asked the provider to take can

be found at the end of this report.

Rating at last inspection: Requires Improvement (report published 11/04/2018). This is the second time that the service has been rated as requires improvement. More information in the full report.

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

Follow up: We have asked the provider to send us an action plan telling us what steps they are to take to make the improvements needed. We will continue to monitor information and intelligence we receive about the service to ensure good quality is provided to people. We will return to re-inspect in line with our inspection timescales for Requires Improvement services.

Inspection areas


Requires improvement

Updated 4 May 2019

The service was not always Safe.

Details are in our Safe findings below.



Updated 4 May 2019

The service was Effective.

Details are in our Effective findings below.


Requires improvement

Updated 4 May 2019

The service was not always Caring.

Details are in our Caring findings below.



Updated 4 May 2019

The service was Responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 4 May 2019

The service was not always Well-Led.

Details are in our Well-Led findings below.