Archived: Trefoil House

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. At the time of inspection 48 people were living at the care home.

Trefoil House is split in to four different 'units' across two floors and can support up to 70 people. The building has been designed and adapted to support people living with dementia. Facilities, such as a hair dressing room and social communal areas are available.

People’s experience of using this service and what we found

Robust procedures to safeguard people from potential harm and abuse were not in place. The providers response to unexplained skin tears and bruises did not always identify their review, nor communication, with the local authority safeguarding team. This is the third inspection which has identified this shortfall.

Care plans and risk assessments were not always reflective of people’s needs. Records provided conflictive guidance to staff; and relatives told us they had not always been involved in the care planning process. People were not always involved in their care and robust care plan auditing did not take place.

Medication processes and administration records did not always follow the providers procedures nor best practice requirements. Medication access was not securely restricted, and security measures relating to the storage of controlled drugs was reduced.

Staff deployment was not always effective to meet the needs of people and mitigate risk. We identified concerns relating to staff moving and handling practices due to reduced staff availability.

Training provided to staff did not include regular dementia training updates. Staff had not completed training in key areas such as positive response to behaviour which may challenge, or end of life care.

The providers quality assurance and governance systems had not identified our findings and did not always drive continuous improvements. Actions from a local authority visit in April 2021 had not been completed, and we did not see evidence of clear provider-led timescales in place.

Despite this, people said they felt safe and relatives told us staff were caring. Staff spoke to people in a dignified and personalised manner, and they told us they took pride in their roles. The home was clean, fresh and inviting. The housekeeping staff were diligent in their duties and reported having ample provisions to ensure the cleanliness of the home.

We had mixed feedback relating to communication. Relatives and staff told us communication could be variable, and concerns were not always followed up. However, we saw several different communication methods during the inspection, and were told by some relatives that the registered manager had acted where shortfalls had been experienced.

Healthcare professionals told us staff were responsive to their advice, and followed their referral processes to ensure people had access to services. Several initiatives were planned at the care home to further increase support available, where a person may experience deteriorating health.

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

Rating at last inspection and update

The last rating for this service was requires improvement (inspection undertaken 09 April 2019; inspection report published 07 May 2019). We had identified a continued breach of regulation 13 (Safeguarding service users from abuse or improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

The service remains rated as requires improvement and has been rated requires improvement for the last two consecutive inspections. We have identified further breaches of regulation which relate to safe care and treatment, staffing and good governance.

Why we inspected

We received anonymous concerns which related to safe staffing levels and the needs of people not being met. During our remote review of the service, we received further information which led us to enquire further about staffing levels and the needs of people. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

Having reviewed the information, we held about the care home, no areas of concern were identified in other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service remains as requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last inspections, by selecting the ‘all reports’ link for Trefoil House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a continued breach in safeguarding people from harm and abuse, and further breaches relating to safe care and treatment, staffing, and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.

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.

Trefoil House provides personal care and accommodation for older people. Many people living at the home were living with some form of dementia. Trefoil House is registered to provide care for up to 70 adults. At the time of this inspection 60 people were living at the home. Trefoil House comprises of a building offering accommodation over two floors.

There was a registered manager in place. 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.

We found some issues relating to fire safety when we visited the home. The fire service had visited eleven months ago. They had advised the provider and the registered manager that the home was not fully legally compliant. No action was taken to rectify this issue until we identified this issue on our visit.

Staff recruitment checks were not fully completed. This is important to ensure people are safe among new staff. A safeguarding event had occurred and the correct process to ensure people’s safety had not been followed. This situation had not been reviewed to ensure lessons were learnt and this situation was not repeated in the future.

We identified and observed shortfalls in staff practice in relation to always treating people with respect and in protecting people’s private information in the home. There were times when staff did not respond to people’s needs in a person centred way. Staff’s knowledge in certain important areas was not complete. There was a lack of sufficient competency checks to monitor staff knowledge and practice was effective.

There was either insufficient staff or a poor deployment of staff, to enable staff to spend time with people in a social way, chatting, and engaging with people. This is an important part of day to day life. Staff were busy with other important care tasks to give people this time. The provider and registered manager had not considered this issue.

The services’ quality monitoring processes were not always effective or robust as they had not identified these issues and taken action to resolve them.

These issues constituted a breach in the legal requirements of the law. There were breaches of Regulation 17, 12 and 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

People had risk assessments in place which identified their needs and the risks they faced. We could see action had been taken to respond to these risks and to meet people’s needs. Although people’s care records did need updating in places and there were some occasions when people’s care plans lacked details, to support staff to meet people’s needs.

People received their medicines as prescribed and most medicines were stored safely. However we found that people’s topical creams were not stored in a safe way, which could have undermined the effectiveness of this medicine. People received medical support when they needed this involvement. Referrals were made to specialist health professionals and their guidance was followed.

Staff received training and induction to their work. However, we found some shortfalls in staff knowledge and understanding which did not have a significant impact on people, but it could do if left unaddressed in the future. We have made a recommendation to improve staff competency checks and training in certain areas.

People spoke positively about the food and drinks they were provided with. People were given real choice on a daily basis to try and ensure people had food and drinks which they liked and enjoyed. People who were at risk of not having enough to eat and drink were being supported and monitored. Although it was not always clear if this information was being analysed effectively, to ensure people’s hydrations needs were being fully met.

Despite the issues we identified in relation to always treating people with respect, we found that the staff were caring and kind towards the people they supported. Staff showed a commitment and willingness to support the people at the home.

There were planned events and activities at the home. The staff associated with this made real efforts to arrange events which people would enjoy. Relatives felt part of the home and the service responded to suggestions and ideas made by people and their relatives. However we found that outside of these events and activities people had limited social stimulation.

There was an open, friendly, and inviting culture at the home. Staff felt confident about approaching the registered manager. The registered manager was committed to ensuring people led positive and happy lives at Trefoil House.

Trefoil House is a residential home in Luton providing care and support to older people, some of whom are living with dementia and physical disabilities. The home is divided into four units with one residential unit, two dedicated dementia units and a unit where nursing care is provided. At the time of our inspection there were 59 people using the service, 15 of whom required nursing care.

There was a registered manager 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 were kept safe from avoidable harm and there were person-centred assessments in place to identify ways to manage risk safely. Staff had a good understanding of how to keep people safe and knew which agencies to contact if they had any concerns over people’s safety. Equipment used in the service to support people with moving and transferring was regularly checked and only used by staff trained to do so. The service had a system for identifying patterns of incidents or falls and was proactive in putting preventative measures into place to reduce these over time. Where people needed support with taking their medicines, these were stored and managed appropriately. Regular health and safety checks were conducted around the service and there were plans in place to support people during any emergencies.

There were enough suitably qualified, trained and experienced staff available to meet people’s needs. People’s dependency had been assessed to ensure that sufficient staff were deployed on shift at different times of day. The staff were employed safely to work in the service using a robust and thorough recruitment process.

Staff received a range of training that was relevant to their role, and this was regularly refreshed and updated. New staff completed a comprehensive program of induction and were subject to regular supervision and performance review thereafter. Staff were able to describe the principles behind the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLs). The service had appropriate authorisations in place if people were deprived of their liberty. People gave consent to receiving care and treatment from the service. People’s healthcare needs were identified and met by the service and the quality of nursing care was evidenced through detailed records and staff knowledge. Appropriate referrals were made to other healthcare professionals where required. People were supported to eat and drink and maintain a healthy and balanced diet that took their individual needs and preferences into account.

The design of the service was innovative and dementia-friendly, with several areas of the building themed to appear period-specific. There were a number of amenities on site which helped people to identify as being part of a wider community and live as independently as possible.

The service demonstrated outstanding care through a person-centred ethos that put people at the heart of their practice. Staff were caring, compassionate and treated people with dignity and respect. During the inspection we noted several examples of creative and innovative care being provided to people living with dementia. The service strived to make people feel comfortable, at home and to develop meaningful and lasting relationships with staff. Relatives were encouraged to spend as much time as possible in the service and their involvement was promoted across all areas of the home.

Each person had a care plan that was personalised, detailed and comprehensive enough to enable staff to support them with their needs. People’s backgrounds, social histories, interests and relationships were included to help develop a holistic picture of the person. Outcomes and interventions were in place to support staff to work towards supporting the person’s development and independence. The service took an innovative approach to activities around the home and had been recognised with a number of awards for the quality and creativity they demonstrated in this area. There was a system in place for handling and resolving complaints.

People, relatives and staff were positive about the management of the service. Staff were able to describe their roles and responsibilities and the values of the provider. There was a positive development program in place to support staff which led to a higher retention rate and greater consistency for people using the service. The systems that the registered manager had in place were effective in monitoring quality across the service. Where improvements were required, these were clearly identified and promptly resolved. Meetings took place between staff, people and their relatives to discuss improvements and the development of the service. Communication with other stakeholders involved with people’s care was strong and evidenced through positive feedback from surveys and questionnaires.

An inspector from the Care Quality Commission conducted this inspection. We looked at eight care records. Spoke with eight people who used the service. We spoke with relatives and a doctor who was visiting the service and staff. We observed the care that was being provided to people around the home.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found.

Is the service safe?

People had up to date risk assessments in place to enable them to be as independent as possible and these were reviewed regularly by staff to ensure that they correctly reflected the needs of the person. The provider had emergency evacuation plans for people who used the service to ensure that in the event of an emergency they would be kept safe.

Is the service effective?

People's care needs were assessed before they came to live at the care home and were again reviewed six weeks after admission to ensure that care plans were written to reflect their individual needs. We observed that people were happy and smiling and talking with staff. People's personal care needs had been met. People were free to move around the home and use the home's shop, caf', and hair dressing service.

Is the service caring?

We observed that staff were caring and compassionate, and treated people with respect and dignity. We saw that staff were patient towards people. For example, we saw that a person who was demonstrating verbal and physical aggression towards a member of staff, the staff was able to de-escalate the situation and calm the person down. We observed that the staff member remained with the person and supported them whilst protecting themselves and other people using the service against harm. We reviewed the person's care plan and saw that the staff had followed the instructions within the care plan and on discussion with the staff member they were able to confirm their understanding of the person's needs and how to manage the aggression. The staff member told us that the person "is lovely, you just need to be aware of how to help them".

Is the service responsive?

We saw that care plans were reviewed and updated on a regular basis to reflect the changing needs of people. The home had activities available for people to participate in and an activity person was also available to organise and plan each activity. On the day of our inspection we saw that some people were going to the home's hair salon to have their hair done. We observed one person walking through the home with their handbag and when we spoke with them, they said they were on their way to get their hair done. They told us that they used the facilities regularly. We saw that the provider acted on feedback received and had addressed the issues raised. For example, each unit had been painted with distinct colours to assist people with recognising their own units. We were told and we also saw from documentation provided that one person had made a complaint about the colours in their unit. We saw that the home had negotiated a resolution with the person, which was beneficial to them and the people on the unit.

Is the service well led?

The service had a registered manager in place.

Quality assurance systems were in place and we saw that the manager had acted on the actions that were identified to improve the quality of service so the home was able to meet the regulations. There were regular audits in place to ensure that the home was meeting the regulations required.

People who used the service and staff were asked for their opinions, and we noted that feedback had been acted on. Where the manager was unable to provide a resolution, they had escalated matters to the head office for further input.

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

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

During the course of our inspection we spoke with seven people and two relatives of people who lived at the home. They told us that they had been involved in planning the care that they or their relative received. One person told us, "They make you feel safe." A relative told us, "I am happy to leave [my relative] here. They are as safe as could be and everything is in place."

On the day of our inspection the home appeared to be clean and bright and was free of any bad odours. The manager showed us around the building and we looked in a random selection of people's rooms. We saw that the rooms and the en-suite facilities were clean and smelled fresh. We spoke with two care workers who were able to demonstrate that they had a good understanding of infection control procedures, including the use of personal protective equipment and effective hand washing. We also saw that the environmental health service had awarded the home's kitchen a rating of five, the highest available.

We noted that the home displayed information for people and their relatives at the reception desk that explained the Deprivation of Liberty Safeguards (DoLS) and who they should contact if they believed they or their relatives were being treated unlawfully. The manager told us that the home was in the process of reviewing their processes to ensure that they were fully compliant with the requirements.

Is the service effective?

People told us that the care workers always knocked on their door before entering their room. One person said, "They look after me well. The food is very good. You get to choose what you want."

We looked at the care records for six people who lived at the home. We saw that these included information on people's social history and their likes and dislikes. These records had been completed by people or their relatives before people's admission to the home and had been reviewed on their admission. We saw that people's needs were evaluated and reviewed by care workers on a monthly basis or more often if a need arose.

However, we saw that the care delivered was not always in line with people's individual care plan. We saw that in one care plan it stated that the person required assistance to turn at intervals of two hours in order to reduce the risk of them developing a pressure ulcer. When we checked the chart, which documented the times the person had been given this assistance, we saw that at times the person had not been assisted to turn for periods of three to four hours.

Is the service caring?

People told us that they were happy with the care that they or their relative received. People who lived in two units of the home were unable to tell us of their experiences. We observed care workers as they interacted with people on these units. We noted that the care workers were patient and caring as they involved people in the activities. We observed the care workers encouraging people to talk together and use the rummage boxes that were available in each of the lounges. These boxes held themed materials which were used to start conversations with people. One box held tools and equipment, another knitting patterns and wools.

Is the service responsive?

One relative told us, "They are aware of [my relative's] likes and dislikes. They always dress [my relative] in the way that [relative] likes, always in a shirt and sometimes a tie if [my relative] wants it."

We saw that the manager held regular monthly meetings with the residents at which the topics discussed included staff changes, complaints, meals, confidentiality, privacy and choices. One person told us that they had initially had problems with a couple of the care workers. They had discussed these with the manager who had listened to their concerns and made alternative arrangements for their care.

We saw that care plans for a person's physical health and mobility needs had been reviewed following a fall that had required a hospital admission. Their care plan reflected the increased needs on their discharge from the hospital and had been reviewed as their recovery had progressed.

Is the service well-led?

People told us that they were happy with the quality of the care that was provided. One person told us, "On the whole it is all right."

We saw that the provider completed an annual survey of people and the relatives of people who lived at the home and that the manager had developed an action plan to address the issues that were raised in the survey completed in 2013.

We saw that at the registered provider's visit in February 2014 the actions arising from the previous visit had been checked as having been completed. A new action plan had been completed arising from the visit.

We saw records of monthly home management audits. We noted that an action plan had been drawn up following the audit completed on 25 February 2014 where actions were identified to address issues identified, such as the bubbling of a carpet on one unit and not all records of accidents had been included in people's care plans.

People said they were satisfied with the care they received from staff at Trefoil House. We observed that staff were attentive to people and treated them with respect and dignity. People looked relaxed in staff's company. A relative of a person who used the service said, 'The care is absolutely excellent and wonderful. I'm in care myself I know what to look for. It's a relief that my'is well looked after.'

We found that people were provided with a choice of suitable and nutritious foods which met their needs.

The systems in place to reduce the risk and spread of infection needed to be improved to ensure that people were protected against the risk of exposure to a health care associated infection.

We found that the premises were safe and adequately maintained. Also the equipment used was safe and fit for its purpose. This meant that people were not at risk of unsafe premises or equipment.

Suitable arrangements were in place to ensure that staff were appropriately supported to deliver care safely and effectively. Records relating to people's care and safety were appropriately maintained.

Many of the people living with dementia were unable to directly express their views on the service so we observed the interactions between them and staff. We found that on one unit some people were left for periods of time with no stimulation or staff interaction and were seen sleeping or just sitting in a chair. On another unit we saw staff being proactive with their interactions and people were chatting and being actively involved.

We spoke with visiting relatives who told us that they were confident that their relative was well looked after by the staff. They said "Overall we are delighted mum is here. We give it the thumbs up'. They also stated that, 'They always keep us informed about our relative's well being".

Relatives told us that they knew how to make a complaint and were confident that it would be responded to promptly.