Archived: Tremethick House

This report only covers our findings in relation to “Is the service Safe, Responsive and Well-led?”. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tremethick House on our website at www.cqc.org.uk

Tremethick House is a care home which offers care and support for up to 42 predominantly older people. At the time of the inspection there were 35 people living at the service. Some of these people were living with dementia.

At the last inspection we were concerned about the medicines administration processes at the service. Since the last inspection the service had reported two further medicine errors. The service use an electronic medicines management system and staff had been trained in its use. At this inspection we found there had been improvements in the processes and practices of medicines administration. Regular audits of the medicines management were helping to identify any errors and reduce the risk of future issues. However, we continued to find prescribed liquids, Gaviscon and Lactulose, in the medicines trolley and prescribed creams in people’s rooms that had not been dated when opened. This meant staff were not aware when the item should be disposed of.

At the last inspection we were concerned that care plans were not always effectively reviewed to take account of any changes in a person’s needs. Risk assessments were not always completed where a risk had been identified. Some people who required monitoring of their position, their weight or their food and drink intake did not always have this recorded by staff. Pressure relieving mattresses used to help reduce the risk of skin damage were not regularly checked to ensure they were set appropriately for each person. The service was not displaying its most recent inspection report as they are legally required to do.

At this inspection we found the service had taken action to help ensure each review of a persons' care plan led to a review of their risk assessments. Risk assessments were in place when concerns had been identified. Staff had improved the recording of when they provided care and support for people, such as re-positioning, food and drink recording and monitoring of peoples' weights. Pressure relieving mattresses were now audited each month following a check of peoples weights to help ensure they were set correctly. The services most recent inspection report was clearly displayed in the entrance hall of the service.

The service had two vacancies for care staff at the time of this inspection. The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. Staff and people told us they felt there were sufficient numbers of staff. The service audited their call bell response times. The report for the week prior to this inspection showed people waited between two and nine minutes for staff to respond, this had improved from the previous two weeks reports showing waits of up to 12 minutes.

People had access to some activities. Activity co-ordinators were in post who arranged regular events for people. These included music and quizzes and some trips out to the local community. However, some people told us that they felt there was not enough to occupy them during the day and at weekends. The management team confirmed they were reviewing activity provision to ensure it was what people enjoyed.

The two acting managers were supported by the operations manager and the provider. The staff told us that morale had improved and that they were working well together. Healthcare professionals told us they had noticed recent improvements in the service provided at Tremethick House and that they felt it was a safer service since the provider had taken action to address concerns.

We found the provider had taken effective action to address the concerns in the two warning notices. However, we still had concerns about the management and administration of medicines.

We have not changed the rating of this service as a period of sustained improvement is required before we can judge the service is entirely safe.

We found a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Tremethick House is a care home which offers care and support for up to 42 predominantly older people. At the time of the inspection there were 37 people living at the service. Some of these people were living with dementia.

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 registered manager was on extended absence at the time of this inspection. There was an acting manager in post supported by the senior management team.

The service used an electronic medicines management system. The management of medicines was not robust. There were suitable arrangements for storing medicines which required extra security. However the records were not always accurate. For example, quantities of liquids were incorrect. One medicine had been disposed of but it was still recorded as in stock in the record book. There were no records for another medicine which legally must be recorded. Weekly checks had been made for these medicines but they had not identified these issues. There were no policies or procedures available for staff to follow for this type of medicine.

An error was found in the recording of one person’s medicines following transfer from the hospital to Tremethick House. Not all staff who administered medicines were fully trained in the use of the electronic medicine system used at the service. Regular effective audits were not taking place and any errors were not being identified in a timely manner.

Care plans were not always effectively reviewed to take account of any changes that may have taken place in a person’s needs. Risk assessments were not always completed when a risk had been identified. This meant there was a lack of information for staff on the action to take to help reduce an identified risk. Some people had been assessed as requiring regular monitoring and re-positioning whilst in bed in order to help prevent pressure damage to their skin. This action was not always recorded as having been followed by staff. Pressure relieving mattresses were regularly audited. However, we found the audit carried out on the day of this inspection was not effective. Mattresses were not always correctly set according to the weight of the person.

Accidents and incidents that occurred at the service were recorded and audited. However, action taken to help reduce the risk of reoccurrence was not evidenced. This meant incidents re-occurred.

At the last inspection the service was not publicly displaying the recent report and rating provided by CQC. At this inspection the service did not display the recent report and rating as they are required to do.

We walked around the service which was comfortable and bedrooms were personalised to reflect people’s individual tastes. People were treated with kindness. There were positive interactions between people and staff. People told us they were happy living at the service. A recent quality assurance survey sought the views of people living at the service and their families. Responses to this survey were largely positive. Action had been taken to respond to some comments made. This meant the service was listening to people's views.

Staff were recruited safely and were supported by a system of induction, supervision and training. Staff were not receiving annual appraisals. People were supported by staff who knew how to recognise abuse and how to respond to concerns. Staff received training relevant for their role and there were opportunities for on-going training and support and development. Staff meetings were held regularly and provided an opportunity for staff to air any concerns or suggestions they had regarding the running of the service and share information.

The service had identified the minimum numbers of staff required to meet people’s needs. The service had one vacancy at the time of this inspection which was being covered by an agency care worker. However, people, relatives and external healthcare professionals commented that there were times when staff were ‘hard to find’ and people reported having to wait for attention. Bells were heard ringing throughout the inspection by people requesting assistance. The call bell response times were audited showing an average response time of approximately 5 minutes.

People's rights were protected because staff acted in accordance with the Mental Capacity Act 2005. The service held an appropriate policy for the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards. Appropriate applications had been made for authorisations for potentially restrictive care plans. However, the records of one person’s DoLS status were out of date and inaccurate. A care plan review had not identified this.

Tremethick House used an external meal provider who delivered a variety of frozen meals to the service. People were provided with a choice of meals according to their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy. However, these records were not always completed by staff at each meal. People’s weight was monitored and recorded. However, the action taken to address the risk and direct staff on how to reduce the risk of further weight loss was not always evidenced. The service had received a three star rating from an inspection of the Food Standards agency. Actions required from this inspection were in the process of being addressed by the provider such as new flooring and kitchen units.

The premises were regularly checked for any defects. The building was warm and mostly clean. Some carpets in the service were soiled and remained so until mid afternoon on the day of the inspection. There were areas of the service that required repair such as damaged doors and corridors from the passage of wheelchairs and moving and handling equipment. People’s bedroom doors were numbered with no other identifying signage. The service did not have any specific pictorial signage to help meet the needs of people living with dementia to orientate them to areas of the building such as bathrooms etc., Equipment such as passenger lift and moving and handling equipment was regularly serviced to ensure it was safe to use.

People had access to a variety of activities. Two activity co ordinators were in post who arranged regular events for people. These included, trips out in the minibus, seasonal events such as at Christmas and on St Patricks day along with visiting entertainers and children, craft and games.

The registered manager was on extended absence at the time of this inspection and the acting manager was supported by the senior management team of Anson Care as well as a team of senior carers, carers and ancillary staff. Staff told us they felt morale was good and that they could access any support they may need.

There were breaches 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.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Following the inspection of 31 March 2016 the provider sent us an action plan setting out the steps the service was taking to address these concerns. We carried out this focused inspection visit to check they had followed their action plan and confirm if they now met the legal requirements.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tremethick House on our website at www.cqc.org.uk

Tremethick House is a residential care home for up to 42 older people. At the time of this focussed inspection visit there were 40 people living at the service, some people were living with dementia.

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.

Tremethick House had installed an electronic records system since the last inspection, which had been fully implemented in June 2016 following a period of transition and training for staff and management.

At this inspection we found care plans were regularly reviewed and contained sufficient information to guide staff to meet people's individual needs. However, risk assessments were not always reviewed regularly. Some risk assessments had not been reviewed since April 2016. The registered manager assured us that the new electronic system would be set up to ensure that such risk assessments were all updated when each care plan was reviewed. Some guidance in people’s care plans was not always followed by care staff. For example, regular re-positioning was required every 2 hours for some people who were cared for in bed. Staff did not always record this in a timely manner and gaps of up to 8 hours were seen when there was no record of the person being re-positioned. We were able to establish that there had been no impact on the person’s wellbeing due to this gap in recording and that care had been provided but not recorded.

The action plan sent to CQC by the provider stated that a key worker system was in place to help improve documentation and communication. This had not yet taken place.

The Deprivation of Liberty Safeguards policy continued to require to be updated to take account of changes that had taken place to the legislation. The safeguarding procedures in the county had changed recently and this was not reflected in the procedure available for staff. The registered manager and quality assurance manager assured us this would be actioned immediately.

The service has a responsibility to display the latest CQC report showing the rating given to the service. The most recent report was not clearly displayed to the public, with only a summary sheet available in the registered managers office. The service’s website did not contain a link to the latest CQC report. We were assured that the service was about the launch a new website and that this would include such a link. The service had not sent a notification to the CQC of a death which had occurred at the service. A notification is information about important events which the service is required to send us by law.

Staff had improved their recording when they had provided care and support to individuals. Where people had been assessed as needing to have their weight monitored regularly we found this was being done and regularly monitored by the registered manager. Actions were taken to address any concerns. People who required regular input from the district nursing service had details of their nurses visits recorded in a new communication book. This meant it was possible to evidence when each person had received such support.

Staff were observed seeking people’s agreement to having a clothes protector placed over their clothes during meals if they wished. People were provided with choices and this was respected. People’s care records detailed if they wished to have their bedroom doors open at all times or preferred to have them closed to protect their privacy.

Audits of pressure relieving mattresses and medicines held by the service were being carried out regularly and were effective in identifying if any issues needed addressing.

At this focused inspection the registered provider had met the requirements of the regulations. However, we could not improve the rating for Responsive and Well-Led from Requires Improvement because to do so required consistent good practice over time. We will check this during our next planned comprehensive inspection.

The last inspection took place on 14 April 2015. At that inspection we found there was a breach of the legal requirements. Following the inspection in April 2015 a new manager was appointed in November 2015. An action plan was submitted outlining how the service would address the identified breach. At this inspection we checked on the actions taken by the service to meet the requirements of the regulations.

Tremethick House is a care home which offers care and support for up to 42 predominantly older people. At the time of the inspection there were 40 people living at the service. Some of these people were living with dementia. The service provides accommodation over two floors. Access to the first floor is provided by two passenger lifts and a chair lift.

The service had 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.

At the inspection in April 2015 we were concerned records held at the service were not always accurate or maintained regularly. Some policies required updating. Staff were not regularly provided with supervision and training support.

At this inspection we found some improvements had been made. However, we had continued concerns about some records held at the service. Staff did not record details of care provided to people living at the service each day. Some records were inaccurate. Where staff had identified when people had lost weight, this was not reported and advice was not sought to address the issue. Risk assessments were not always reviewed and updated in a timely manner. Care plans did not always contain sufficient guidance and accurate information for staff about people’s care needs. For example when a person required dressings by the district nurses. Accident forms were not always completed for incidents that took place at the service.

We walked around the service which was comfortable and personalised to reflect people’s individual tastes. People were treated with kindness. However, we did see some people were not always provided with privacy and respect. Clothes protectors were placed over people’s heads at mealtimes by staff who had not sought the person’s informed consent first. People’s bedroom doors remained open when they were sleeping.

Staff told us they felt well supported by the management of the service and could access any assistance they may need at any time. The action plan sent in by the service following our previous inspection stated; “Supervisions/care competencies/reflective practice are being carried out, and documented on a matrix.” However, the records showed that 25 of the 38 staff had not had any formally recorded face to face supervision recently. One member of staff did not have any record of supervision for 2015 or 2016. The service had not provided any annual appraisals for staff at the time of this inspection.

We looked at how medicines were managed and administered. The service had implemented an electronic medicines management system. We were able to establish if people had received their medicines as prescribed. Regular medicines audits were not being carried out at the time of this inspection although the electronic medicines system was able to produce these. Medicines that required stricter controls were checked. The record book showed the service had held a stock of a specific medicine since 2014. This had been entered ‘in error’ but the records still showed a balance of medicine being held. This was addressed immediately. The error had not been picked up by regular medicine checks which we were told were being carried out, although they were not recorded. The service was not storing any medicines that required cold storage. The medicine policy had been fully reviewed and updated since the last inspection.

Staff were supported by a system of induction and training when they began working at the service. Records showed most staff had undertaken appropriate training to meet the needs of people living at the service. However, one member of staff who had worked for the service for some months did not have any evidence of having completed moving and handling training.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service was fully staffed.

Staff knew how to recognise and report the signs of abuse and were aware of how to report any concerns. Staff meetings were held occasionally. Staff told us they felt the management listened to them and provided good support.

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.

The service had two activities co ordinators. Activities were provided regularly. People told us they enjoyed the varied activites held in the lounge.

The registered manager was supported by a head of care and two deputy heads of care. The provider regularly visited the service to support the registered manager and the staff team.

People were aware of how to raise any concerns they may have. The complaints policy held at the service had been reviewed since the last inspection and contained accurate information.

We found there was a continued breach of Regulation 17 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.

We considered our inspection findings to answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. We saw a range of records about people's care and how the home was managed. This included four people's care plans, staff training records, staff rotas and documents in respect of the homes quality assurance systems.

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

Is the service safe?

We judged the service to be safe on the day of our inspection

People at Tremethick House who we were able to communicate with told us they felt safe living there. Due to people's complex health needs we were not able to communicate with everyone verbally. Therefore we spent time observing people.

We spoke with four members of staff about what action they would take if they suspected abuse was taking place. They told us they would have no hesitation in reporting it to the manager and were confident their concerns would be acted on.

The registered manager and the staff we spoke with were aware of the Mental Capacity Act 2005 legislation including the recent Supreme Court judgement regarding the responsibility on providers to consider if people living at the home are subject to continuous supervision and not free to leave. The provider told us they were in the process of completing applications for potential authorisations from the local authority under the Deprivation of Liberty Safeguards (DoLS) legislation.

We saw risk assessments had been completed and regularly reviewed in the files we saw. This ensured people were supported to stay safe whilst minimising restrictions.

We saw the staffing rota for the week of this inspection. We saw there were six staff on shift in the mornings and three/four staff on shift in the afternoon/evenings. At night we saw there were two staff on shift.

The registered manager showed us the computerised electronic system used at Tremethick House to record the length of time call bells rang before care staff responded. We were told the system was regularly monitored and any call bells that were found to have been unanswered for longer than six minutes were raised at staff handover meetings which were held daily.

Is the service effective?

We judged the service was not effective on the day of our inspection.

Care records were held in files which did not hold the pages securely. When the files were opened pages became loose and fell out. Confidential information about people at the home was seen openly available on landings and in corridors and not held securely.

Staff we spoke with were knowledgeable about the people they cared for. We saw staff training was recorded.

Staff told us they felt well supported on a day-to-day basis by both the head of care and the registered manager and could approach them at any time. We were told they had daily handover meetings regarding each person at the home but did not have regular documented staff meetings. We were told staff were not currently having regular formal documented supervision.

We spoke with four people who lived at Tremethick House. Most could not recall having been asked for their views and experiences of living at the home. One person could recall having completed a questionnaire. We were told by the registered manager, residents meetings were not well attended in the past, so not held any more. We did see evidence of a questionnaire that had been sent out to people in May 2014 with 12 responses. It was not clear how the management was actively seeking the views and experiences of people who had not, or could not, respond to this written , or healthcare professionals who visited, in order to inform the continued improvement of the service provided.

We saw evidence that people were able to access healthcare professionals as required, for example, GP, district nurses and social workers.

We were told by the registered manager one person had been referred to a health care professional for assessment due to concern about their food intake, however, there was no record of this concern in the person's records. This person was not having their food and fluid intake monitored. This meant the service was not able to ensure this person had adequate nutrition and hydration.

We saw one person's care plan stated 'monitor weight regularly'. We did not see evidence this was carried out. We did not see any record of why this was not carried out. We were told by staff who knew this person that they 'ate very well'. We did not see any records to support this in the care file.

We heard people were offered choices throughout the day of our inspection. We heard care staff asking people where and how they wished to spend their day, and what they wished to eat for their meals.

Is the service caring?

We judged the service to be caring on the day of our inspection.

We observed staff caring for people with patience and understanding. People who lived at Tremethick House told us the staff were kind and caring. They told us they felt they were given the time they required to make decisions.

Staff we spoke with were aware of people's individual care needs, their personal histories and current preferences and choices.

People we spoke with told us staff responded quickly when they rang for assistance.

We did not see any evidence of the involvement of the person, or their representatives, in their own care plan reviews. People were not asked to sign in agreement to the content of their individual care plans. People we spoke with were not always aware of the content of their care plan.

We spoke with visitors who told us they felt they could visit their family/friends at any time. They told us they found the staff to be kind and approachable.

Is the service responsive?

We judged the service to be responsive on the day of our inspection.

We saw care plans directed and informed staff how to meet people's needs and were regularly reviewed to take account of any changes.

We saw there was a comprehensive programme of activities that people could take part in if they chose. Tremethick House has an activities co-ordinator who works between the group of care homes. Some people chose to spend time in their rooms. These people told us staff spent time with them in their rooms. This meant people would not become too socially isolated.

Is the service well-led?

We judged the service to be well-led on the day of our inspection.

There was a positive culture evident during our inspection. We were told the management was regularly present in the home and had a good knowledge of the staff and the dependency status of all the people who lived at Tremethick House. This ensured there were sufficient numbers of appropriate staff available when required.

We were told about expected changes in the members of staff working at night which were being actively planned for and recruited to. This meant there were always sufficient numbers of staff available to cover shifts.

Staff told us they found the registered manager and the head of care to show good leadership.

We saw accidents and incidents were recorded at the home by staff. These records were audited on a monthly basis to monitor any trends or patterns that were evidence and thus reduce any re-occurrence.

We saw the records of complaints and concerns that had been raised at the home. We saw these had been investigated and responded to in a timely manner.

We saw evidence that the registered manager had sent out a quality assurance questionnaire to people at Tremethick House. It was not clear how the management sought the views and experiences of visiting healthcare professionals of the service provided at the home.

Staffing levels and the deployment of staff ensured the care needs of people who used the service were met at the time of our inspection. Staff we spoke with confirmed there were sufficient staff on duty to meet people's care needs. People who used the service told us the staff responded promptly to them when they required assistance.

The record relating to people who used the service were factual, legible and stored securely.

The home was clean, tidy, hygienic and odour free on the day of our inspection.

We saw and were told by people who used the service, their visitors and staff on duty that the staff were busy with some periods throughout the day busier than others. Two people, who remained in their rooms, said they did not often see the staff as they were so busy.

People and their relatives and / or representatives knew how to make a complaint, were confident they would be listened to and action taken. However, people we spoke with said they had no concerns. One person told us they had previously raised an issue with the home and it had been addressed thoroughly and to their satisfaction.

Records relating to people who used the service were stored securely and their personal and confidential information was protected. Records, for example care plans and risk assessments did not consistently provide sufficient detail to inform and direct staff on the action they had to take to ensure people's assessed care needs were met.

We found that records relating to people who used the service were stored securely and their personal and confidential information was protected. Records, for example care plans and risk assessments did not consistently provide sufficient detail to inform and direct staff on the action they had to take to ensure people's assessed care needs were met.

People who used the service told us they were well cared for and like to live at Tremethick House. Comments made included: : 'I came here for a short period and decided I liked it and am going to stay, they look after me very well', 'If I have to be somewhere this is a good place to be, the staff are lovely' and 'I am cared for here, if I need anything I ring my bell and they [the staff] come straight away'. A visitor to the home who we spoke with said the staff communicated with them well regarding their relative's care and they were made to feel welcome in the home.

People who used the service were protected from unsuitable staff as the home followed a robust recruitment procedure.

We heard some people who used the service thought the staff were always busy. As a result we were told on occasions people had to wait to receive assistance they had requested. The registered provider agreed to review the staffing levels and deployment of staff within the home.

We saw the home was clean, tidy, pleasantly decorated and furnished and free from odours.

People's confidential and personal information was not always stored securely.